Devices and techniques for treating metatarsus adductus

ABSTRACT

A metatarsus adductus technique may involve cutting an end of one or both of a second metatarsal and an intermediate cuneiform to create a wedge-shaped opening between the end of the second metatarsal and the intermediate cuneiform. The method may further involve cutting an end of one or both of a third metatarsal and a lateral cuneiform to also create a wedge-shaped opening between the end of the third metatarsal and the lateral cuneiform. The second metatarsal and the third metatarsal can then be moved in a transverse plane to close a metatarsus adductus angle. Movement of the second and third metatarsal may close the wedge-shaped openings forming during bone cutting. With the second and third metatarsals appropriately realigned, the clinician can fixate the moved position of the second metatarsal and the third metatarsal.

CROSS REFERENCE

This application claims the benefit of U.S. Provisional PatentApplication No. 63/027,340, filed May 19, 2020, and U.S. ProvisionalPatent Application No. 63/126,207, filed Dec. 16, 2020, the entirecontents of each of which are incorporated herein by reference.

TECHNICAL FIELD

This disclosure relates to devices and techniques for treatingmetatarsus adductus.

BACKGROUND

Metatarsus adductus (MTA) is a deformity of the foot in which themetatarsals are angulated into adduction. MTA is typically characterizedby a medial deviation of the metatarsals in the transverse plane. Forexample, MTA is often described as a structural deformity occurring atthe Lisfranc joint (tarsometatarsal joints), with the metatarsals beingdeviated medially with reference to the lesser tarsus.

In some patients, MTA presents with hallux valgus, also referred to ashallux abducto valgus. Hallux valgus is a complex progressive conditionthat is characterized by lateral deviation (valgus, abduction) of thehallux and medial deviation of the first metatarsophalangeal joint.Hallux valgus typically results in an increase in the hallux adductusangle, which is the angle between the long axes of the first metatarsaland proximal phalanx in the transverse plane.

In some cases, surgical intervention is needed to address MTA and/orhallux valgus deformities. Surgical intervention may involve realigningone or more bones of the foot, improving patient comfort and increasingpatient mobility.

SUMMARY

In general, this disclosure is directed to devices and techniques fortreating metatarsus adductus (MTA), either alone or in combination withtreatment of hallux valgus. In some implementations, a cliniciansurgically accesses the second and third tarsometatarsal joints of thefoot to prepare the joints for realignment and fusion. The clinician maymake an incision, e.g., providing dorsolateral and dorsomedial access,to the second and third tarsometatarsal joints. With the joints exposed,the clinician may prepare the end faces of the second and thirdmetatarsals and opposed intermediate and lateral cuneiforms,respectively. With or without the use of a cut guide, the clinician maycut an end of at least one of the bones forming the secondtarsometatarsal joint and also cut an end of at least one of the bonesforming the third tarsometatarsal joint. The cut may be angled relativeto an end face of the bone being cut so as to define an opening betweenthe two bones, such as a wedge expanding from a narrow end (e.g., apex)to a wider end (e.g., base). Once the bone slice (e.g., wedge) isremoved from the joint space, a gap (e.g., wedge-shaped gap) may existbetween the end of the metatarsal and opposed cuneiform. For example,the narrower portion of the wedge may be on the medial side of the jointwhile the wider portion of the wedge may be on the lateral side of thejoint. The metatarsal can be rotated in at least the transverse plane,with or without the use of a bone positioning guide, to close thewedge-shaped gap formed by cutting and removing the bone wedge. Forexample, the metatarsal may be moved in the transverse plane, rotated inthe frontal plane, and/or moved in the sagittal plane to realign themetatarsal. This can help realign the bone to correct the metatarsaladductus deformity (or other bone condition being treated).

In some implementations, the second and third tarsometatarsal joints areprepared and the second and third metatarsals independently moved fromeach other in one or more planes, such as the transverse plane. In otherimplementations, the second and third tarsometatarsal joints can beprepared and the second and third metatarsals move together to addressthe angular misalignment of the metatarsals. For example, when accessingand preparing the second and third tarsometatarsal joints, the plantartarsometatarsal ligaments and the ligaments between the second and thirdmetatarsals may be preserved (e.g., remain uncut or unbroken). This canmaintain the connective tissue between the second and third metatarsals,allowing the second and third metatarsals to be manipulated as aninterconnected block or group during angular realignment.

For instance, in one implementation, the clinician may access the secondand third tarsometatarsal joints and then prepare the ends of the secondand third metatarsals as well as the ends of the intermediate andlateral cuneiforms. The clinician may cut an end of at least one of thesecond metatarsal and the intermediate cuneiform, e.g., to define awedge-shaped opening between two bone faces. The clinician may also cutan end of at least one of the third metatarsal and the lateralcuneiform, e.g., to define a wedge-shaped opening between two bonefaces. The clinician can then move the second and third metatarsalstogether, e.g., by applying a force to the second metatarsal alone,applying a force to the third metatarsal alone, or by applying a forceto both the second and third metatarsals. In any case, the distal endsof the second and third metatarsals can move laterally in at least thetransverse plane while the proximal ends of the second and thirdmetatarsals pivot to close the opening (e.g., wedge-shaped gap) formedduring bone preparation. The Lisfranc ligament may serve as a tetheringpoint at the base of the second metatarsal around which rotation of thesecond and third metatarsals occurs. In some implementations, a softtissue release is performed between the third and fourth metatarsals tohelp mobilize the third metatarsal and allow reorientation.

In addition to realigning the second and third metatarsals, the fourthand fifth metatarsals may also be realigned to help correct themetatarsal adductus. The distal ends of the fourth and fifth metatarsalsmay naturally pivot laterally in the transverse plane upon forciblemovement of the second and/or third metatarsals. For example, when thesecond and third metatarsals are moved individually or as aninterconnected block, rotation of the metatarsals may cause naturalrealignment (e.g., lateral pivoting of the distal ends) of the fourthand fifth metatarsals in at least the transverse plane. The forceapplied to the second and third metatarsals may translate through tissue(e.g., one or more ligaments) interconnecting the second and thirdmetatarsals with the fourth and fifth metatarsals. In differentimplementations, the fourth and/or fifth tarsometatarsal joints may ormay not be surgically accessed and prepared for fusion (e.g., bypreparing the end of the fourth and/or fifth metatarsal and/or preparingthe end of the cuboid bone opposite the metatarsal for fusion).Realignment of one or more lesser metatarsals also results inrealignment of a remainder of the digit, e.g., the proximal phalanx andother interconnected bones.

With one or more lesser metatarsals realigned in one or more planes(e.g., at least the transverse plane), the clinician can fixate themoved position of the one or more metatarsals. In some examples, theclinician may provisionally fixate one or more moved metatarsals beforepermanently fixating the moved position. For example, the clinician mayinsert a fixation pin through the second metatarsal into another bonesuch as the lateral cuneiform and/or insert a fixation pin through thethird metatarsal into another bone such as the intermediate cuneiform.With or without provisional fixation, the clinician may permanentlyfixate a moved bone position, e.g., by applying a fixation device acrossthe second tarsometatarsal joint and/or across the third tarsometatarsaljoint.

While a surgical technique according to the disclosure may involvesurgically accessing and preparing multiple lesser tarsometatarsaljoints of the foot, such as the second and third tarsometatarsal jointsas discussed above, in alternative implementations a technique can beperformed on a single lesser tarsometatarsal joint (e.g., the secondtarsometatarsal joint, the third tarsometatarsal joint, the fourthtarsometatarsal joint, and/or the fifth tarsometatarsal joint). Thisprocedure on the single lesser tarsometatarsal joint may be performedeither alone or in combination with treatment of hallux valgus on thefirst metatarsal. For example, a MTA deformity or other bone deformitymay be corrected by operating on a single lesser tarsometatarsal joint(e.g., the second tarsometatarsal joint, the third tarsometatarsaljoint) without operating on other lesser tarsometatarsal joints, againoptionally with alignment correction of the first metatarsal through aprocedure performed on the first tarsometatarsal joint.

For example, the surgeon may access the second tarsometatarsal joint,the third tarsometatarsal joint, or yet other lesser tarsometatarsaljoint. The surgeon can prepare the end of the metatarsal (e.g., secondmetatarsal, third metatarsal) and/or the end of the bone on the otherside of the joint (e.g., intermediate cuneiform, lateral cuneiform). Insome examples, the clinician cuts the end of each of the bones separatedby the tarsometatarsal joint. The clinician can then apply a force toone or more of the lesser metatarsals (e.g., the metatarsal withprepared end, an adjacent metatarsal with unprepared end). The force maymove the metatarsal in one or more planes, such as the transverse planeand/or frontal plane, to realign the metatarsal. In someimplementations, the force moves substantially only the lessermetatarsal being surgically accessed and operated on to realign thelesser metatarsal. In other examples, the force moves the lessermetatarsal being surgically accessed and operated on and one or more(e.g., all) other adjacent and/or lesser metatarsals to realign multiplebones in the foot.

In situations where the patient also presents with a first metatarsalangular deformity such as hallux valgus, the clinician may also performa first metatarsal realignment. The first metatarsal realignment may beperformed before or after realignment of a lesser metatarsal (second,third, fourth, and/or fifth metatarsals) or may be performed at leastpartially concurrent with the process of realigning the lessermetatarsal. For example, the clinician may realign the lessermetatarsals and, before or after fixating the moved position of therealigned lesser metatarsals, realign the first metatarsal in one ormore planes.

To realign the first metatarsal, the clinician may perform an incisionacross the first tarsometatarsal joint to access the joint. With thejoint exposed, the clinician may prepare the end of the first metatarsaland also prepare the opposed end of the medial cuneiform. Before orafter preparing one or both bone ends, the clinician can move the firstmetatarsal in one or more planes. For example the clinician may pivotthe distal end of the first metatarsal in the transverse plane to closean intermetatarsal angle between the first and second metatarsals.Additionally or alternatively, the clinician may rotate the firstmetatarsal in the frontal plane and/or adjust the angular alignment ofthe first metatarsal in the sagittal plane. With the first metatarsalsuitably realigned, the clinician can fixate the moved position of thefirst metatarsal.

Independent of the specific surgical technique performed during atreatment procedure, a variety of different instruments may be providedto help facilitate bone preparation and/or realignment techniques. Theinstruments may be utilized as part of a metatarsal adductus treatmentprocedure or yet other treatment procedure (e.g., fusion of an arthriticjoint, realignment of a bone other than a metatarsal). For example, abone cutting guide may be used to help cut an end face of a metatarsaland/or cuneiform to facilitate realignment and/or fusion between bones.In general, the bone cutting guide may be sized and shaped to bepositioned over one or more bones to be cut. The bone cutting guide maydefine at least one guide surface along which a cutting instrument canbe guided to cut a bone in a plane parallel to the guide surface. Forexample, the bone cutting guide may define a pair of guide surfacesdefining a cutting slot there between through which a cutting instrumentcan be inserted.

In some examples, a bone cutting guide defines a guide surfaceconfigured to be positioned on a dorsal side of a metatarsal and/orcuneiform (or cuboid) to be cut. The bone cutting guide may include alocating feature (e.g., a spacer or pin) that can be inserted in a jointspace between adjacent bones and/or into a bone, respectively, to helpposition the guide surface over the bone to be cut. The spacer or pinmay be fixedly (e.g., non-movably) connected to the guide surface or maybe movable relative to the guide surface. For example, when the spaceror pin is movable relative to the guide surface, the spacer or pin maybe inserted into a joint space or inserted into a bone and the structuredefining the guide surface then inserted down over the spacer or pin orotherwise attached to the spacer or pin (e.g., via a clamp, pin, screw,or other attachment mechanism). In some configurations, the guidesurface can rotate about the spacer or pin, for example within arestricted angular range of travel, to allow the clinician to adjust thepositioning of the guide surface over the bone to be cut by rotating theguide surface about the pin or spacer. Once suitably positioned, one ormore other fixation pins may optionally be used to lock the position ofthe cut guide relative to the bone to be cut.

A bone cutting guide configured for a surgical procedure (e.g.,metatarsal adductus procedure) may have a guide surface for guidingcutting of a single bone or may be configured to guide a cuttinginstrument to cut multiple different bones. For example, the bonecutting guide may include at least one guide surface (e.g., at least onecutting slot) to guide a cutting instrument to cut an end of ametatarsal and at least one additional guide surface (e.g., at least oneadditional cutting slot) to guide a cutting instrument to cut an end ofan opposed cuneiform. The guide surfaces may be angled relative to eachother, e.g., with the angle opening toward the lateral side of the foot,when the cutting guide is installed on the foot. The angle between theguide surfaces may be fixed or may be adjustable. When configured withan adjustable angle, the clinician may adjust the angle between oneguide surface positionable over a metatarsal to be cut in another guidesurface positionable over an opposed bone (e.g., cuneiform) to be cut.

When the intermediate and lateral cuneiforms opposing the second andthird metatarsals, respectively, are prepared through cutting, thecuneiforms may be cut individually or may be cut together. In oneimplementation, for example, a cut guide may be used that has anelongated guide surface configured to extend over both the intermediatecuneiform and the lateral cuneiform. The guide surface may be parallelto an adjacent guide surface to define a cutting slot. The cutting slotmay be positionable on a dorsal side of the intermediate and lateralcuneiforms, extending from at least the medial side of the intermediatecuneiform to the lateral side of the lateral cuneiform. When soconfigured, a clinician may guide a cutting instrument along the guidesurface (e.g., through the cutting slot) to cut both the intermediatecuneiform and the lateral cuneiform. This can result in the intermediatecuneiform and the lateral cuneiform having parallel cut end faces, whichcan help realignment to close the metatarsal adductus angle.

In addition to or in lieu of using a bone cutting guide, a bonepreparation template may be provided that the surgeon can overlay on oneor more bones to be prepared to mark locations for preforming asubsequent bone preparation step. The bone preparation template mayinclude one or more orienting features relative to one or moreunderlying bones (e.g., a metatarsal, cuneiform, and/or joint line)indicating one or more locations where the bones should be cut orotherwise prepared. The surgeon may use the bone preparation template toimpart indicia on one or more underlying bones where preparation shouldoccur. The surgeon may subsequently perform guided and/or freehand bonepreparation (optionally removing the bone preparation templatebeforehand) to prepare the one or more bones at the location markedusing the bone preparation template. The surgeon may move and/or fixateone or more bones as discussed in conjunction with the use of a bonecutting guide.

In one example, a method for treating metatarsus adductus is described.The method includes cutting an end of at least one of a secondmetatarsal and an intermediate cuneiform to create a wedge-shapedopening between the end of the second metatarsal and the intermediatecuneiform. The method also involves preparing an end of the other of thesecond metatarsal and intermediate cuneiform. The method furtherincludes cutting an end of at least one of a third metatarsal and alateral cuneiform to create a wedge-shaped opening between the end ofthe third metatarsal and the lateral cuneiform. The method also involvesmoving the second metatarsal and the third metatarsal in a transverseplane to close a metatarsus adductus angle. The method also specifiesfixating a moved position of the second metatarsal and the thirdmetatarsal.

In another example, a method for treating metatarsus adductus isdescribed. The method includes positioning a cuneiform-side guidesurface of a cutting guide over a dorsal side of an intermediatecuneiform and over a dorsal side of a lateral cuneiform and positioninga metatarsal-side guide surface of the cutting guide over a dorsal sideof a second metatarsal facing the intermediate cuneiform and over adorsal side of a third metatarsal facing the lateral cuneiform. Themethod involves using the cuneiform-side guide surface to advance acutting tool in a plane parallel to the cuneiform-side guide surface toremove a portion of the intermediate cuneiform and to remove a portionof the lateral cuneiform and using the metatarsal-side guide surface toadvance the cutting tool in a plane parallel to the metatarsal-sideguide surface to remove a portion of the second metatarsal and to removea portion of the third metatarsal. The method includes moving the secondmetatarsal and the third metatarsal in a transverse plane to close ametatarsus adductus angle and fixating the moved position of the secondmetatarsal and the third metatarsal.

In another example, a bone cutting guide for use in a metatarsusadductus procedure is described. The bone cutting guide may include acuneiform-side guide surface configured to be positioned over a dorsalside of both an intermediate cuneiform and a lateral cuneiform of a footwith the cuneiform-side guide surface being configured to guide acutting instrument to cut the intermediate cuneiform and the lateralcuneiform. The bone cutting guide may also included a metatarsal-sideguide surface configured to be positioned over a dorsal side of both asecond metatarsal and a third metatarsal of the foot with themetatarsal-side guide surface being configured to guide the cuttinginstrument to cut the second metatarsal and the third metatarsal.According to the example, the cuneiform-side guide surface and themetatarsal-side guide surface are each spaced from each other by adistance configured to cross a second metatarsal joint between theintermediate cuneiform and the second metatarsal and a third metatarsaljoint between the lateral cuneiform and the third metatarsal.

In some aspects of the example, the cuneiform-side guide surfaceincludes a continuous cuneiform-side guide surface configured to extendfrom a medial-most side of the intermediate cuneiform to a lateral-mostside of the lateral cuneiform. In some aspects of the example, themetatarsal-side guide surface includes a continuous metatarsal-sideguide surface configured to extend from a medial-most side of the secondmetatarsal to a lateral-most side of the third metatarsal. In someaspects of the example, the metatarsal-side guide surface includes afirst cuneiform-side guide surface configured to extend across thesecond metatarsal and a second cuneiform-side guide surface configuredto extend across the third metatarsal.

In some aspects of the example, the cuneiform-side guide surface definesa first cuneiform-side guide surface and further includes a secondcuneiform-side guide surface parallel to the first cuneiform-side guidesurface to define a cuneiform-side cutting slot therebetween.Additionally, the metatarsal-side guide surface defines a firstmetatarsal-side guide surface and further includes a secondmetatarsal-side guide surface parallel to the first metatarsal-sideguide surface to define a metatarsal-side cutting slot therebetween.

In some aspects of the example, an angle between the cuneiform-sideguide surface and the metatarsal-side guide surface is fixed. In otheraspects of the example, the angle between the cuneiform-side guidesurface and the metatarsal-side guide surface is adjustable. In someaspects of this example, the bone cutting guide further includes a lockconfigured to lock the adjustable angle. In some aspects of the example,an angle between the cuneiform-side guide surface and themetatarsal-side guide surface is within a range from 1 degree to 40degrees, such as from 5 degrees to 20 degrees.

In some aspects of the example, the bone cutting guide further includesat least one locating feature associated with the bone cutting guide,where the at least one locating feature is configured to be insertedinto at least one of a bone and a joint between adjacent bones toposition the bone cutting guide. In some aspects of the example, thelocating feature includes a spacer configured to be positioned at leastpartially within both the second metatarsal joint and the thirdmetatarsal joint and bridging between the second metatarsal joint andthe third metatarsal. In some aspects of the example, the spacer tapersin a dorsal to plantar direction along its length.

In some aspects of the example, the bone cutting guide further includesat least one fixation hole configured to receive a fixation pin forpinning the bone cutting guide to an underlying bone, the at least onefixation hole being adjustable in at least one dimension. In someaspects of the example, the fixation hole is adjustable along a lengthof the bone cutting guide.

In another example, a bone cutting guide is described that includes acuneiform-side guide surface configured to be positioned over at leastone cuneiform of a foot with the cuneiform-side guide surface beingconfigured to guide a cutting instrument to cut the at least one ofcuneiform. The bone cutting guide also includes a metatarsal-side guidesurface configured to be positioned over at least one metatarsal withthe metatarsal-side guide surface being configured to guide the cuttinginstrument to cut the at least one metatarsal. The example bone cuttingguide also includes at least one fixation hole configured to receive afixation pin for pinning the bone cutting guide to an underlying bonethat is adjustable in at least one dimension. In some aspects of theexample, the fixation hole is adjustable along a length of the bonecutting guide. In some aspects of the example, the fixation hole isrotationally adjustable relative to bone cutting guide.

The details of one or more examples are set forth in the accompanyingdrawings and the description below. Other features, objects, andadvantages will be apparent from the description and drawings, and fromthe claims.

BRIEF DESCRIPTION OF DRAWINGS

FIGS. 1A and 1B are top and front views, respectively, of a foot showingnormal metatarsal alignment positions.

FIGS. 2A and 2B are top and front views, respectively, of a foot showingan example metatarsal adductus bone misalignment.

FIG. 3A illustrates the different anatomical planes of a foot.

FIG. 3B illustrates the metatarsus adductus of the foot from FIGS. 2Aand 2B characterized by a metatarsus adductus angle.

FIG. 4 is a flow diagram illustrating an example technique for preparingTMT joints for fusion and realigning multiple metatarsals to treat ametatarsus adductus deformity.

FIG. 5A is a top view of a foot showing an example cut guide positionedover the second and third TMT joints to illustrate example bone wedgesthat may be cut during joint preparation.

FIGS. 5B-5E illustrate example bone preparation steps that may beperformed on a foot using an example cutting guide.

FIG. 6 is a diagram schematically illustrating the ligament structure ofthe foot.

FIG. 7A is a side perspective view of an example bone positioner thatcan be used to move a metatarsal relative to an adjacent bone.

FIG. 7B is an illustration of an example compressor engaged with a footto facilitate movement of the second and third metatarsals.

FIG. 8A is a dorsal view of an example radiographic image illustratingan example provisional fixation pin arrangement.

FIG. 8B is a dorsal view of an example radiographic image illustratinganother example provisional fixation pin arrangement.

FIGS. 9A and 9B are dorsal radiographic images of an example foot beforeand after a treatment procedure, respectively, performed following asurgical technique discussed with respect to FIG. 4.

FIG. 10 is a top view of a foot showing the example cut guide introducedwith respect to FIG. 5A.

FIG. 11 is a top view of a foot showing another example configuration ofa cut guide.

FIGS. 12A and 12B are top views of a foot showing another exampleconfiguration of a cut guide.

FIG. 13 is a top view of an example configuration of a cut guide inwhich an angle between a distal-most guide surface and a proximal-mostguide surface of the guide is fixed.

FIG. 14A is a top view of another example configuration of a cut guidein which an angle between a distal-most guide surface of the cut guideand a proximal-most guide surface of the guide is variable.

FIG. 14B illustrates an example of cut guide have separate guidesurfaces for cutting two metatarsals where the angular position of theguide surfaces are both adjustable.

FIG. 15 is a perspective view of a foot illustrating an example locatingfeature that can be used with a cut guide.

FIG. 16 illustrates an example cut guide engaged with and being advancedplantarly along a locating feature to help orient the bone guide overone or more bones to be cut.

FIGS. 17 and 18 illustrate two different configurations of a cut guidein which the cut guide is restricted to a limited range of rotationalmovement relative to a spacer or pin insertable into an underlying bonestructure.

FIG. 19 is perspective view of an example cut guide with associatedlocating feature.

FIG. 20 is a front perspective view of a foot showing the cut guide ofFIG. 19 positioned over a dorsal side of one or more bones to be cut.

FIG. 21 is a top view of the foot with engaged cut guide of FIG. 20.

FIG. 22 is a perspective view of an example cut guide having twoassociated locating features.

FIGS. 23A-23I illustrate example target locations on the foot forinserting one or more locating features associated with a cut guide.

FIG. 24 is a perspective view of an example configuration of a cut guidehaving at least one adjustable fixation hole.

FIG. 25 is a top view of the example cut guide of FIG. 24 showingexample positions to which adjustable fixation holes can be moved.

FIGS. 26A and 26B are top images of an example foot showing the cutguide of FIGS. 24 and 25 positioned on the foot.

FIGS. 27A and 27B are top view illustrations of an example configurationof a cut guide showing an example linkage between two adjustablefixation holes.

FIGS. 28A and 28B are top view illustrations of an example configurationof a cut guide showing example rotational realignment positions for anadjustable fixation hole.

FIG. 29 is an image of an example patient's foot showing a distal offsetbetween a second TMT joint and a third TMT joint.

FIG. 30 is a perspective illustration of an example cutting guide thatcan be used to remove a protruding bone portion.

FIG. 31 is top view of a foot showing an example positioning of thecutting guide of FIG. 30.

FIG. 32 is a perspective illustration of a foot showing an example cutguide and blocking element, where the blocking element is positioned tolimit movement of a cutting instrument to help prevent inadvertentcutting of an adjacent metatarsal.

FIG. 33 is a perspective view of an example bone preparation templatethat defines one or more guiding surfaces that can be used to guide amarking instrument.

DETAILED DESCRIPTION

In general, the present disclosure is directed to devices and techniquesfor preparing one or more tarsometatarsal joints (“TMT joint”) forfusion and realigning one or more metatarsals separated from an opposedbone by the tarsometatarsal joint. While a technique according todisclosure can be performed on any TMT joint, in some implementations, asurgical technique is performed on at least the second TMT joint and thethird TMT joint. During the procedure, the clinician may cut an end ofone or both of the second metatarsal and opposed intermediate cuneiform.Additionally or alternatively, the clinician may cut an end of one orboth of the third metatarsal and opposed lateral cuneiform. In someexamples the clinician advances a cutting instrument along a path (e.g.,a linear path and/or a curved path) to cut one metatarsal end followedby another metatarsal end and/or to cut one cuneiform end followed byanother cuneiform end. In either case, a bone portion may be removedfrom the TMT joint space, such as between both the second TMT jointspace and the third TMT joint space. The bone portion and/or space fromwhich the bone portion is removed may be shaped to facilitate subsequentrepositioning of the metatarsal relative to the opposed cuneiform, e.g.,by moving the metatarsal to partially or fully close the space createdupon removal of the bone portion.

Independent of how one or more TMT joints are prepared, the cliniciancan apply a force to one or more metatarsals, such as the second and/orthird metatarsals, to rotate the one or more metatarsals in at least oneplane (e.g., one or more of the transverse plane, frontal plane, and/orsagittal plane). When repositioning both the second and thirdmetatarsals, the second and third metatarsals may or may not remaininterconnected through ligamentous attachments, such as the plantarligaments and/or second-to-third intermetatarsal ligaments. Whenremaining interconnected, the second and third metatarsals may bepivoted together as a block (e.g., in at least one plane, such as thetransverse plane). For example, the second and third metatarsals maypivot generally about a medial aspect (e.g., side) of the second TMTjoint in the transverse plane, closing a larger opening on the lateralside of the joint. In some implementations, the second and/or thirdmetatarsals may be pivoted in at least the transverse plane with thesecond metatarsal base being attached to the Lisfranc ligament to serveas a pivot point about which the bone block can rotate. The cliniciancan pivot the second and third metatarsals by hand and/or with the aidof a bone positioner that engages with at least one of the second andthird metatarsals and a bone other than that with which the bonepositioner is engaged.

The fourth and fifth metatarsals may also be pivot in one or more planes(e.g., at least the transverse plane), such as concurrent with thesecond and/or third metatarsals being pivoted in one or more planes. Thefourth and fifth metatarsals may realign without accessing or preparingthe fourth or fifth TMT joints. That being said, in some examples, thefourth and/or fifth metatarsals may be surgically accessed and preparedby prepared an end of the fourth metatarsal and/or opposed cuboid boneand/or an end of the fifth metatarsal and/or opposed cuboid bone. Aftersuitably realigning one or more of the second, third, fourth and/orfifth metatarsals, the moved position of the one or more metatarsals maybe fixated. In some examples, a provisional fixation step is performedin which one or more temporary fixation pins are deployed to hold themoved position of one or more metatarsals (e.g., by inserting thefixation pin through one or more moved metatarsal and into one or moreadjacent bones). A permanent fixation device can be used to hold a movedposition of a bone for subsequent fusion. Example permanent fixationdevices include, but are not limited to, pins (e.g., intramedullarynail, K-wire, Steinmann pin), plates, screws, staples, and combinations.

Before, after, or concurrent with preparing and moving one or morelesser metatarsals (e.g., one or more of the second, third, fourth,and/or fifth metatarsals), the clinician may prepare and move the firstmetatarsal. The clinician may prepare the end of the first metatarsaland also prepare the opposed end of the medial cuneiform. Before orafter preparing one or both bone ends, the clinician can move the firstmetatarsal in one or more planes. For example the clinician may pivotthe distal end of the first metatarsal in the transverse plane to closean intermetatarsal angle between the first and second metatarsals.Additionally or alternatively, the clinician may rotate the firstmetatarsal in the frontal plane and/or adjust the angular alignment ofthe first metatarsal in the sagittal plane. With the first metatarsalsuitably realigned, the clinician can fixate the moved position of thefirst metatarsal. Details on example first metatarsal realignmentinstruments and techniques that can be used in conjunction with thepresent disclosure are described in U.S. Pat. No. 9,622,805, issued Apr.18, 2017 and entitled “BONE POSITIONING AND PREPARING GUIDE SYSTEMS ANDMETHODS,” U.S. Pat. No. 10,245,088, issued Apr. 2, 2019 and entitled“BONE PLATING SYSTEM AND METHOD,” US Patent Publication No.2020/0015856, published Jan. 16, 2020 and entitled“COMPRESSOR-DISTRACTOR FOR ANGULARLY REALIGNING BONE PORTIONS,” and USPatent Publication No. 2020/0015870, published Jan. 16, 2020 andentitled “MULTI-DIAMETER BONE PIN FOR INSTALLING AND ALIGNING BONEFIXATION PLATE WHILE MINIMIZING BONE DAMAGE.” The entire contents ofeach of these patent documents are incorporated herein by reference.

Preparation and fusion of one or more TMT joints may be performedaccording to the disclosure for a variety of clinical reasons andindications. Preparation and fusion of a TMT joint may be performed totreat metatarsus adductus, hallux valgus, and/or other bone and/or jointconditions.

Metatarsus adductus is a deformity of the foot characterized by atransverse plane deformity where the metatarsals are adducted at theLisfranc joint. The extent of a metatarsus adductus deformity can becharacterized by a metatarsus adductus angle. The metatarsus adductusangle can be defined as the angle between the longitudinal axis of thesecond metatarsal (representing the longitudinal axis of the metatarsus)and the longitudinal axis of the lesser tarsus. The measurement of thelongitudinal axis of the lesser tarsus can be characterized by a lineperpendicular to the transverse axis of the lesser tarsus using thelateral joint of the fourth metatarsal with the cuboid as a reference.

Hallux valgus, also referred to as hallux abducto valgus, is a complexprogressive condition that is characterized by lateral deviation(valgus, abduction) of the hallux and medial deviation of the firstmetatarsophalangeal joint. Hallux valgus typically results in aprogressive increase in the hallux adductus angle, the angle between thelong axes of the first metatarsal and proximal phalanx in the transverseplane. An increase in the hallux adductus angle may tend to laterallydisplace the plantar aponeurosis and tendons of the intrinsic andextrinsic muscles that cross over the first metatarsophalangeal jointfrom the metatarsal to the hallux. Consequently, the sesamoid bones mayalso be displaced, e.g., laterally relative to the firstmetatarsophalangeal joint, resulting in subluxation of the jointsbetween the sesamoid bones and the head of the first metatarsal. Thiscan increase the pressure between the medial sesamoid and the crista ofthe first metatarsal head.

While techniques and devices are described herein particularly inconnection with TMT joints of the foot, the techniques and/or devicesmay be used on other similar bones separated by a joint in the hand orfoot. For example, the techniques and devices may be performed on thecarpometacarpal joints of the hand. As another example, one or moretechniques and/or devices may be used on a metatarsal and/or phalanx,e.g., across a metatarsophalangeal joint. In various implementations,the devices and/or techniques can be used as part of a bone alignment,osteotomy, fusion, fracture repair, and/or other procedure where one ormore bones are to be prepared and/or moved to a desired position.

Further, while the techniques and devices described herein are generallydiscussed in connection with preparation and fusion of the second and/orthird TMT joints, the devices and techniques are not limited to thesespecific anatomical locations or being performed together. In variousexamples, devices and/or techniques of the disclosure may be utilized toprepare and promote fusion across a single TMT joint (e.g., the firstTMT joint the second TMT joint, the third TMT joint, the fourth TMTjoint, the fifth TMT joint) and/or any combination of TMT joints (e.g.,the first and second TMT joints; the second and third TMT joints; thefirst and third TMT joints; the first, second, and third TMT joints; thefirst and fourth TMT joints; the first, second, and fourth TMT joints,etc.).

To further understand example techniques of the disclosure, the anatomyof the foot will first be described with respect to FIGS. 1-3 along withexample misalignments that may occur and be corrected according to thepresent disclosure. As noted, a bone misalignment may be caused bymetatarsus adductus, hallux valgus (bunion), and/or other condition. Thecondition may present with a misalignment of one or more bones in thefoot.

FIGS. 1A and 1B are top and front views, respectively, of a foot 10showing normal metatarsal alignment positions. Foot 10 is composed ofmultiple bones including a first metatarsal 12, a second metatarsal 14,a third metatarsal 16, a fourth metatarsal 18, and a fifth metatarsal20. First metatarsal 12 is on a medial-most side of the foot while fifthmetatarsal 20 is on a lateral-most side of the foot. The metatarsals areconnected distally to phalanges 22 and, more particularly, each to arespective proximal phalanx. The joint 24 between a metatarsal and acorresponding opposed proximal phalanx is referred to as ametatarsophalangeal (“MTP”) joint. The first MTP joint is labeled asjoint 24 in FIG. 1A, although second, third, fourth, and fifth MTPjoints are also illustrated in series adjacent to the first MTP joint.

The first metatarsal 12 is connected proximally to a medial cuneiform26, while the second metatarsal 14 is connected proximally to anintermediate cuneiform 28, and the third metatarsal 16 is connectedproximally to lateral cuneiform 30. The fourth and fifth metatarsals 18,20 are connected proximally to the cuboid bone 32. The joint between ametatarsal and opposed bone (cuneiform, cuboid) is referred to as thetarsometatarsal (“TMT”) joint. FIG. 1A designates a first TMT joint 34,a second TMT joint 36, a third TMT joint 38, a fourth TMT joint 40, anda fifth TMT joint 42. The angle between adjacent metatarsals is referredto as the intermetatarsal angle (“IMA”).

In the example of FIGS. 1A and 1B, foot 10 is illustrates as havinggenerally normally aligned metatarsals. Normal metatarsal alignment maybe characterized, among other attributes, by a low intermetatarsal angle(e.g., 9 degrees or less, such as 5 degrees or less) between the firstmetatarsal and the second metatarsal. In addition, the lessermetatarsals may be generally parallel to a longitudinal axis bisectingthe foot proximally to distally.

FIG. 3A illustrates the different anatomical planes of foot 10,including frontal plane 52, transverse plane 54, and sagittal plane 56.The frontal plane 52, which is also known as the coronal plane, isgenerally considered any vertical plane that divides the body intoanterior and posterior sections. On foot 10, the frontal plane 52 is aplane that extends vertically and is perpendicular to an axis extendingproximally to distally along the length of the foot. The transverseplane 54, which is also known as the horizontal plane, axial plane, ortransaxial plane, is considered any plane that divides the body intosuperior and inferior parts. On foot 10, the transverse plane 54 is aplane that extends horizontally and is perpendicular to an axisextending dorsally to plantarly (top to bottom) across the foot.Further, the sagittal plane 56 is a plane parallel to the sagittalsuture which divides the body into right and left halves. On foot 10,the sagittal plane 56 is a plane that extends vertically and intersectsan axis extending proximally to distally along the length of the foot.

For patients afflicted with metatarsal adductus, at least one or more ofthe lesser metatarsals (the second through fifth metatarsals) may bedeviated medially in the transverse plane (e.g., in addition to or inlieu of being rotated in the frontal plane and/or being deviated in thesagittal plane relative to clinically defined normal anatomicalalignment for a standard patient population). FIGS. 2A and 2B are topand front views, respectively, of foot 10 showing an example metatarsaladductus bone misalignment. As shown in this example, the metatarsalsare deviated medially relative to an axis bisecting the foot. This canresult in an abnormal biomechanical structure benefiting from surgicalintervention. FIG. 3B illustrates the metatarsus adductus of foot 10from FIGS. 2A and 2B being characterized by a metatarsus adductus angle50.

Bone positioning techniques and instruments can be useful to correct amisalignment of one or more bones, such as a metatarsal adductus and/orhallux valgus metatarsal misalignment. FIG. 4 is a flow diagramillustrating an example technique for preparing TMT joints for fusionand realigning one or more (e.g., multiple) metatarsals to treat atleast a metatarsus adductus deformity. The technique will be describedwith respect to the bone numbering introduced with respect to FIGS. 1Aand 1B, although may be performed on other bones. For purposes ofdiscussion, the technique of FIG. 4 will be discussed with respect todifferent example images, although may be performed without suchinstrumentation or with different instrumentation, as discussed herein.

With reference to FIG. 4, the example technique includes surgicallyaccessing at least the second TMT and third TMT joints (100). Tosurgically access the joints, the clinician may make one or moreincisions (e.g., on a dorsal side of the foot) exposing the second andthird TMT joints. The clinician may dissect through the skin,subcutaneous tissue, and fascia. The clinician may mobilize the extensordigitorum brevis muscle belly from the extensor hallucis brevis andretract the muscle. Soft tissue and/or bone overgrowth may be removed tofacilitate joint visualization.

In instances where the clinician is also performing a first metatarsalcorrection, the clinician may also surgically access the first TMTjoint. Although the clinician may make a single incision spanning thefirst, second, and third TMT joints, a dual incision approach can avoidunnecessary cutting and scarring. With the dual incision approach, theclinician may make one incision providing dorsal (e.g., dorsolateral anddorsomedial) access (and/or, in other examples, medial access) to thefirst TMT joint and a second incision providing dorsal (e.g.,dorsolateral and dorsomedial) to the second and third TMT joints,resulting in an intermediate portion of skin between the first andsecond incisions. When making a dual incision, the surgeon maysurgically access the first TMT joint before, after, or concurrent withsurgically accessing the second and third TMT joints.

In practice, it may be challenging for a clinician to quickly andaccurately locate the position of one or more TMT joints on thepatient's foot, particularly one or more lesser TMT joints that may beoffset because of a bone deformity. The clinician may utilize a jointfinding guide (e.g., incision guide) to help identify the location of aTMT joint, e.g., before making an incision through the skin and/or aftermaking an incision to help find the joint subcutaneously. As oneexample, the joint finding guide may be an instrument fabricated atleast partially from a radiopaque material to designate the location ofthe TMT joint under imaging. For example, the joint finding guide mayinclude one or more radio-identifiable marking lines that aredistinguishable from a remainder of the guide under imaging. The one ormore radio-identifiable marking lines can be formed from a differentmaterial than a remainder of the guide, have a different thickness thana remainder of the guide, and/or otherwise be distinguishable underimaging from the remainder of the guide. In either configuration, theclinician may align a radio-identifiable marking feature (e.g., line)with a TMT joint under imaging to designate the location forsubsequently accessing a joint. The clinician may take a fluoroscopic(e.g. X-ray) image of at least a portion of foot 10 encompassing thetarget TMT joint prior to making an incision and/or after making theincision. The clinician can use the radio-identifiable marking on thejoint finding guide to designate the location of the joint, e.g., tosubsequently make an incision over the joint and/or to release the jointat the designated location.

As another example, the joint finding guide may take the form of a toolconfigured (e.g., sized and/or shaped) to allow the clinician tophysically probe in the region of the TMT joint until the tool depressesinto the TMT joint. For example, the joint finding guide may be aflat-head screw driver, rod, or other instrument. The tool may have ablunt tip and/or may be selected to minimize or prohibit bone cutting orother bone removal as the tool may contact bone while probing for theTMT joint. The clinician may probe for the joint using the tool prior tomaking an incision and/or after making the incision.

Thus, in various examples, the clinician may identify a TMT joint spaceby visual and/or tactile inspection and/or through radiographic (e.g.,fluoroscopic) imaging. Independent of whether the clinician utilizes oneor more joint finding guides to help locate a TMT joint, the cliniciancan make an incision to surgically expose the joint. With the jointexposed, the clinician may optionally release soft tissue from eachaccessed TMT joint (e.g., by inserting a cutting instrument in thejoint) to help mobilize the joint for subsequent realignment.

With access to the TMT joint spaces, the technique of FIG. 4 involvespreparing the end faces of the bones forming the second TMT joint 36 inthe third TMT joint 38. In particular, the clinician can prepare the endof the second metatarsal 14 facing the second TMT joint (102), preparethe end of the third metatarsal 16 facing the third TMT joint (104),prepare the end of the intermediate cuneiform 28 facing the second TMTjoint (106), and/or also prepare the end of the lateral cuneiform 30facing the third TMT joint (108). While FIG. 4 schematically illustratesan example order in which the bones defining the second and third TMTjoints can be prepared, it should be appreciated that the surgicaltechnique is not limited to any particular order of preparation. Forexample, the clinician can prepare one or both cuneiforms beforepreparing one or more metatarsals, can prepare one or both metatarsalsbefore preparing one or more cuneiforms, can prepare the ends of onemetatarsal and one cuneiform defining one TMT joint before preparing thebone ends of the other TMT joint, or perform bone preparation in yetanother order.

In general, the clinician can prepare the end of each bone forming a TMTjoint so as to promote fusion of the bone ends across the TMT jointfollowing realignment. Bone preparation may involve using a tissueremoving instrument, which may also be referred to as a cuttinginstrument, to apply a force to the end face of the bone so as to createa bleeding bone face to promote subsequent fusion. Example tissueremoving instruments that can be used include, but are not limited to, asaw, a rotary bur, a rongeur, a reamer, an osteotome, a curette, and thelike. The tissue removing instrument can be applied to the end face ofthe bone being prepared to remove cartilage and/or bone. For example,the tissue removing instrument may be applied to the end face to removecartilage (e.g., all cartilage) down to subchondral bone. Additionallyor alternatively, the tissue removing instrument may be applied to cut,fenestrate, morselize, and/or otherwise reshape the end face of the boneand/or form a bleeding bone face to promote fusion. In instances where acutting operation is performed to remove an end portion of a bone, thecutting may be performed freehand, with the aid of a cutting guidehaving a guide surface positionable over the portion of bone to be cut,and/or with the aid of a bone preparation template. When using a cuttingguide, a cutting instrument can be inserted against the guide surface(e.g., between a slot defined between two guide surfaces) to guide thecutting instrument for bone removal. When using a bone preparationtemplate, the bone preparation template can be used to mark or otherwisedesignate where on one or more bones a preparation step (e.g., cutting)should be performed. The clinician may then preform a freehand bonepreparation step (e.g., cutting) at a location indicated through use ofthe bone preparation template.

In some examples, the clinician cuts at least one bone defining thesecond TMT joint (e.g., one or both of second metatarsal 14 andintermediate cuneiform 28) and also cuts at least one bone defining thethird TMT joint (e.g., one or both of third metatarsal 16 and thelateral cuneiform 30). The clinician may cut both bones defining thesecond TMT joint or may cut only one bone defining the joint and performa different preparation technique on the other bone. Similarly, theclinician may cut both bones defining the third TMT joint or may cutonly one bone defining the joint and perform a different preparationtechnique on the other bone.

Where the clinician cuts at least one bone forming a TMT joint, eachsuch cut may be parallel or non-parallel to the end of the bone beingcut in one or more of the frontal, transverse, and sagittal planes. Forexample, the cut may be angled in the transverse plane relative to theend face of the bone and parallel to the end face of the bone in thefrontal plane. As other examples, the cut may be curved, arced,spherical, zig-zag, or may define other desired cut shape to facilitaterealignment and fusion of one bone relative to another bone portion. Insome examples, the end faces of the two bones defining the TMT joint areeach prepared by cutting an end portion of each bone to create a shapedopening between the end faces. The opening may have a shape that allowsthe bones to be repositioned relative to each other (e.g., partially orfully closing the opening created in the process of realignment) tofacilitate realignment and subsequent fusion.

In one example, the clinician can cut the end of the bone being preparedat an angle relative to the end face in the transverse plane, creating awedge-shaped section of bone that is released from a remainder of thebone being cut. This can create a wedge-shaped opening between the newlydefined end of the bone being cut and the opposing bone across the TMTjoint being prepared. The wedge-shaped opening may enlarge moving fromthe medial side of the TMT joint to the lateral side of the TMT joint.For example, the wedge-shaped bone portion and corresponding opening mayhave a generally triangular-shape. The wedge-shaped opening can providea gap across the TMT joint that can be closed by subsequently pivotingthe metatarsal in the transverse plane. Again, however, other shapedcuts can be performed on one or both bones facing the TMT joint withoutdeparting from the scope of the disclosure. Example bone cutting shapesand configurations that may be used on one or more bone ends defining aTMT joint are described in U.S. Pat. No. 10,512,470, dated Dec. 24, 2019and titled “OSTEOTOMY PROCEDURE FOR CORRECTING BONE MISALIGNMENT” andU.S. Pat. No. 10,582,936, dated Mar. 10, 2020, and titled “DEVICES ANDTECHNIQUES FOR PERFORMING AN OSTEOTOMY PROCEDURE ON A FIRST METATARSALTO CORRECT A BONE MISALIGNMENT,” the entire contents of both of whichare incorporated herein by reference.

FIG. 5A is a top view of foot 10 showing an example cut guide 150positioned over the second and third TMT joints to illustrate examplebone wedges that may be cut during joint preparation. In this example,cut guide 150 is shown defining a first guide surface 152 (which isillustrated as a cutting slot) positioned over a portion of a secondmetatarsal 14 and a portion of a third metatarsal 16 to be cut. Cutguide 150 is also shown as defining a second guide surface 154 (which isillustrated as a cutting slot) positioned over a portion of anintermediate cuneiform 28 and a lateral cuneiform 30 to be cut. Theclinician can advance a cutting instrument parallel to first guidesurface 152 to cut an end of second metatarsal 14 and also to cut an endof third metatarsal 16. The clinician can also advance the cuttinginstrument parallel to second guide surface 154 to cut an end ofintermediate cuneiform 28 and lateral cuneiform 30. In differentimplementations, a guide surface of cut guide 150 may be linear, curved,and/or define yet other shapes. According, the step of guiding a cuttinginstrument parallel to the guide surface may result in a linear cut, acurved cut, or yet other shaped cut across the bone.

In the example of FIG. 5A, first guide surface 152 is illustrated asbeing angled in the transverse plane across the second and thirdmetatarsals 14, 16. The first guide surface 152 is illustrated as beingangled from a medial-proximal side of second metatarsal 14 toward alateral-distal side of third metatarsal 16. The lateral-distal side ofthird metatarsal 16 may still be on the proximal half of the metatarsal,albeit comparatively distal to the proximal location on the secondmetatarsal. By preforming an angled cut relative to the end faces of thebones being cut, a wedge-shaped bone portion may be released from thebone. In FIG. 5A, a wedge-shaped section 156 of second metatarsal 14 isreleased upon cutting the second metatarsal. Further, a wedge-shapedsection 158 of third metatarsal 16 is released upon cutting the thirdmetatarsal. Each wedge-shaped section of bone removed via cutting mayhave a narrow width (e.g., apex) on a medial side of the bone being cutand a wider width (e.g., base) on a lateral side of the bone being cut.The degree of angulation in the specific dimensions of the bone wedgeformed during cutting may vary depending on the anatomy of the patientand the extent of the deformity being corrected. In either case, thebone wedges so cut can be removed from the TMT joint spaces to define awedge-shaped opening relative to an opposed bone.

In the example of FIG. 5A, the clinician can use second guide surface154 to guide the cutting instrument to cut an end of intermediatecuneiform 28 and lateral cuneiform 30 to promote fusion followingrealignment of the metatarsals. The cuts performed on the intermediatecuneiform 28 and lateral cuneiform 30 may be generally parallel to theend face of a bone being cut (e.g., in the transverse plane) or may beangled relative to an end face of the bone being cut. In still otherexamples, the end faces of one or both of intermediate cuneiform 28 andlateral cuneiform 30 may not be cut but may be prepared using adifferent technique as discussed above (e.g., fenestrated).

In some examples in which the second metatarsal 14 and the thirdmetatarsal 16 are prepared by cutting, the metatarsals may be cut usinga single continuous cut across both metatarsals. For example, theclinician may guide a cutting instrument linearly from a medial side ofthe second metatarsal 14 toward the lateral side of the third metatarsal16 or from the lateral side of the third metatarsal to the medial sideof the second metatarsal. In either case, the clinician may form acontinuous cut line transecting the ends of the second and thirdmetatarsals. Such a continuous cut across the bases of the second andthird metatarsals may be useful to promote reliable reduction of themetatarsus adductus angle during subsequent bone realignment. Inapplications where the intermediate cuneiform 28 and the lateralcuneiform 30 are cut in addition to or in lieu of the ends of themetatarsals, the two cuneiforms may or may not be cut using such acontinuous cut across the ends of the two metatarsals.

In other applications of the surgical technique, the ends of the secondmetatarsal 14 and third metatarsal 16 may be cut independently (e.g.,without moving the cutting instrument in a continuous cutting lineacross the two metatarsals). For example, when the patient exhibits asignificant step off (e.g., distal offset) between the end of theintermediate cuneiform 28 and the end of the lateral cuneiform 30, theends of the opposed second and third metatarsals 14, 16 may be preparedindependently (e.g., through two separate cuts) in lieu of forming acontinuous cut across the ends of the two metatarsals. The ends of theopposed second and third metatarsals 14, 16 may be preparedindependently for other reasons as well, such as to provide independentcontrol/adjustability over the cut angles on the second and thirdmetatarsals.

While FIG. 5A illustrates one example cutting guide 150 and one examplecutting arrangement that may be used to prepare the ends of the secondand third TMT joints, it should be appreciated that a technique inaccordance with the disclosure is not limited to such example guide orcutting arrangements. For example, a technique according to disclosuremay be performed freehand (without the use of a cutting guide) or may beperformed with a cutting guide having a different configuration. Inaddition to or in lieu of using a cutting guide, the clinician mayposition a bone preparation template over one or more bone portions tobe subsequently cut. The bone preparation template may be configured(e.g., sized and/or shaped) to indicate where on the underlying bone thebone should be cut or otherwise prepared. Positioning the bonepreparation template on the underlying bone may mark or otherwiseindicate on the bone where the bone should be prepared and/or theclinician may use the bone preparation template to mark where on thebone the bone should be prepared. The clinician may subsequently removethe bone preparation template and preform a bone preparation step (e.g.,cutting) at the location marked or otherwise indicated using thetemplate.

Further, although FIG. 5A illustrates angled cuts being performed on theends of second metatarsal 14 and third metatarsal 16, such angled cutsare not required. In general, any one or both of the metatarsal andcuneiform bones forming the TMT joint being prepared may be cut so as toestablish an opening for rotating the metatarsal in one or more planes(e.g., the transverse plane) and/or facilitating realignment of one ormore bones. The other of the bones forming the TMT joint may also beprepared by cutting or may be prepared using a different bonepreparation technique.

As one example, the clinician may remove a wedge-shaped section 156 ofbone from the second metatarsal and remove a wedge-shaped section 158 ofbone from the third metatarsal. The clinician can cut, fenestrate,and/or otherwise prepare the ends of the opposed intermediate cuneiform28 and lateral cuneiform 30. In another example, the clinician mayremove a wedge-shaped section of bone from the intermediate cuneiform 28and/or remove a wedge-shaped section of bone from the lateral cuneiform30. The clinician can cut, fenestrate, and/or otherwise prepare the endsof the opposed second metatarsal 14 and third metatarsal 16. In stillanother example, the clinician may remove a wedge-shaped section of bonefrom the cuneiform of one of the second and third TMT joints and removea wedge-shaped section of bone from the metatarsal of the other of thesecond and third TMT joints. The end face of the opposed bone may be cutparallel to the end face of the bone, at an angle, and/or otherwiseprepared (e.g., with or without cutting). For example, the clinician mayremove a wedge-shaped section of both from the ends of both bonesforming the TMT joint. In either case, the opening created between theends of the bones defining the TMT joint may be defined by thecumulative amount of bone removed from both bone ends. As noted above,depending on the characteristics of the patient undergoing the surgicalprocedure, in yet other embodiments the clinician may not cut the endfaces of the bones defining the second and third TMT joints or mayperform a bone cut parallel to the end face of the bone. Further, whilethe foregoing examples are described as being performed by removing awedge-shaped section of bone, a bone section having another shape can beremoved, as described herein.

In instances where the clinician cuts the end face of the bone, theclinician may or may not perform one or more additional preparationsteps on the end face prior to or after cutting the end face. In someexamples, the clinician fenestrates the newly-formed end face of thebone after cutting the bone. The clinician may use a drill to fenestratethe end newly-formed end face of the bone being cut, which can helppromote subsequent fusion of the bone following realignment. Theclinician may fenestrate a bone face by making multiple openings (e.g.,drill holes) in the bone face, providing multiple bleeding points in theend of the bone face. Each drill hole may be comparatively smallrelative to the cross-sectional area of the end face, such as less than10% of the cross-sectional area of the end face, less than 5% of thecross-sectional area of the end face, or less than 1% of thecross-sectional area of the end face. The multiple openings can bearrayed at different locations across the end face to provide locationsfor promoting fusion across the end face. The number of holes formedduring fenestration may vary and, in some examples, is greater than 5,such as greater than 10.

As another example of a preparation step that may be performed, theclinician may remove one or more protruding bone portions extending intoand/or across the second TMT and/or third TMT joint line. The protrudingbone portions may extend distally from the cuneiform into the jointspace and/or proximally from the metatarsal into the joint space. Forinstance, as discussed in greater detail with respect to FIG. 29,certain patients may exhibit significant step off, or distal offset,between adjacent joint planes (e.g., between the plane defining thesecond TMT joint and the plane defining the third TMT joint). This caninhibit relative movement between the two joints for subsequentrealignment and/or inhibit insertion of a cutting guide into one or bothjoint spaces. For these and other reasons, the clinician may remove theone or more protruding bone portions, e.g., to create a pocket orcontinuous joint line extending across the second TMT joint and thethird TMT joint. The clinician may remove the one or more protrudingbone portions using a cutting instrument either freehand and/or with theaid of a cutting guide, such as cutting guide 292 discussed in greaterdetail with respect to FIG. 30.

As another example, the clinician may typically visualize the locationof a cutting guide and/or bone preparation template under radiographicimaging (e.g., fluoroscopy), e.g., to ensure that one or more guideplanes or other guide features are appropriately positioned relative toone or more underlying bones. The clinician can adjust the position ofthe cutting guide or bone preparation template under imaging, e.g.,until one or more guide planes or other alignment features arepositioned over a desired portion or region of underlying bone to bemarked, cut, and/or otherwise prepared.

FIGS. 5B-5E illustrate example bone preparation steps that may beperformed on foot 10 using an example configuration of cutting guide 150according to a technique of the disclosure. In particular, FIGS. 5B and5C are perspective and top (dorsal) view illustrations of foot 10showing cut guide 150 positioned over a dorsal side of the foot.Specifically, cut guide 150 is shown with first guide surface 152positioned over a portion of second metatarsal 14 and a portion of thirdmetatarsal 16 to be cut, and second guide surface 154 is positioned overa portion of intermediate cuneiform 28 and lateral cuneiform 30 to becut. In this example, cut guide 150 defines at least one fixationaperture positionable over each of second metatarsal 14, thirdmetatarsal 16, intermediate cuneiform 28, and lateral cuneiform 30. Aclinician can insert fixation pins through one or more (e.g., all) ofthe fixation apertures to secure the cut guide to underlying bone.

In use, the clinician can guide a cutting instrument along first guidesurface 152 to cut an end of second metatarsal 14 and also to cut an endof third metatarsal 16. The clinician can also guide the cuttinginstrument along second guide surface 154 to cut an end of intermediatecuneiform 28 and lateral cuneiform 30. FIG. 5D is a perspective view ofthe foot showing example bone portions that can be removed aftercutting, specifically illustrating an example wedge-shaped section 156removed from second metatarsal 14 and an example wedge-shaped section158 removed from third metatarsal 16. Additional bone sections may beremoved from intermediate cuneiform 28 and lateral cuneiform 30. FIG. 5Eillustrates an example opening 157 formed between second metatarsal 14and intermediate cuneiform 28 upon removal of one or more bone portionsand an example opening 159 formed between third metatarsal 16 andlateral cuneiform 30 upon removal of one or more bone portions.

With further reference to FIG. 4, the example technique involves movingthe second metatarsal 14 and the third metatarsal 16 in at least oneplane (110). While FIG. 4 schematically illustrates an example order inwhich the second and third metatarsals 14, 16 are moved after preparingthe end faces of metatarsals 14, 16 and opposed intermediate and lateralcuneiforms 28, 30, other orders of bone preparation and movement may beperformed. For example, the clinician can move the second and/or thirdmetatarsals 14, 16 before preparing one or more metatarsals and/or oneor more cuneiforms (e.g., before preparing the end faces of all of thebones). For instance, the clinician may move the second and thirdmetatarsals 14, 16 and then prepare the end faces of metatarsals 14, 16and opposed intermediate and lateral cuneiforms 28, 30. In theseimplementations, the clinician may or may not further move the secondand/or third metatarsals 14, 16 after preparing the end faces of themetatarsals and cuneiforms. As another example, the clinician mayprepare the end face of one or more bones (e.g., one or more metatarsalsand/or cuneiforms), move one or both of second metatarsal 14 and thirdmetatarsal 16, and then prepare the end face of one or more other bones(e.g., one or more metatarsals and/or cuneiforms).

Independent of the order of movement and bone preparation, the clinicianmay move the second and third metatarsals 14, 16 in one or more planes,such as the transverse plane, e.g., by pivoting the metatarsals abouttheir proximal ends, causing a distal end of the metatarsals to movelaterally in the transverse plane. In instances where a wedge-shapedopening was formed at the second and/or third TMT joints during bonepreparation, lateral rotation of the distal ends of the second and thirdmetatarsals may close the wedge-shaped opening(s) (or close anothershaped opening, in instances in which a non-wedge-shaped opening wascreated). For example, translation of the distal ends of the second andthird metatarsals 14, 16 laterally in the transverse plane may bring theends of the second metatarsal 14 and opposed intermediate cuneiform 28as well as the ends of the third metatarsal 16 and opposed lateralcuneiform 30 in generally parallel alignment. The clinician may move thesecond and/or third metatarsal in the frontal plane and/or sagittalplane in addition to or in lieu of moving one or both bones in thetransverse plane. For example, the clinician may rotate one or bothbones in the frontal plane and/or translate one or both bones (e.g.,dorsally) in the sagittal plane.

In general, movement of second metatarsal 14 and third metatarsal 16 inthe transverse plane can close the metatarsus adductus angle. Themetatarsus adductus angle may be the angular measurement formed betweenthe line bisecting the second metatarsal and the longitudinal linebisecting the lesser tarsus on a dorsoplantar radiograph. In someexamples, the second and third metatarsals 14, 16 are moved until themetatarsus adductus angle for each metatarsal is 15° or less, such as12° or less, 10° or less, 7° or less, 5° or less, or 3° or less.

The second metatarsal 14 and third metatarsal 16 may be movedindividually or jointly (e.g., as a bone block). Moving the second andthird metatarsals 14, 16 as a joined group may be helpful to achieve amore natural realignment of the metatarsals and correction of themetatarsus adductus deformity. To help move the second and thirdmetatarsals 14, 16 as a joined group, the ligaments between the twometatarsals may be preserved during preparation of the second and thirdTMT joints. For example, the plantar TMT ligaments and ligaments betweenthe second and third metatarsals 14, 16 may be preserved (e.g., remainuncut or unbroken) during preparation and movement of the second andthird metatarsals. Preserving the ligament structure can help avoiddestabilization of the second and third TMT joints during deformityreduction, which may improve the anatomical realignment of the bonestructure.

FIG. 6 is a diagram schematically illustrating the ligament structure ofthe foot. As shown, the plantar TMT ligaments include a second plantartarsometatarsal ligament between medial cuneiform 26 and the second andthird metatarsals 14, 16. The plantar TMT ligaments also include a thirdplantar tarsometatarsal ligament between lateral cuneiform 30 and thirdmetatarsal 16. A first plantar intermetatarsal ligament extends betweensecond metatarsal 14 and third metatarsal 16. Ligamentous attachmentsbetween the second and third metatarsals, such as the second and thirdplantar tarsometatarsal ligaments and the first plantar intermetatarsalligament, may be preserved during preparation and movement of the secondand third metatarsals to correct the metatarsus adductus. This may allowthe two metatarsals to move together as a joined bone group.

To move the second and third metatarsals 14, 16, either alone or incombination, the bones may be pivoted about their proximal base, causingthe distal ends of the bones to translate laterally in the transverseplane. When moving the second and third metatarsals 14, 16 as a group,the clinician may pivot the second and third metatarsal bone block aboutthe proximal medial portion of second metatarsal 14. The clinician maymove the second and third metatarsals 14, 16 as a combined group in thetransverse plane, with or without simultaneously rotating both bones inthe frontal plane and/or adjusting the sagittal plane position of thebones. In some implementations, the clinician moves the second and thirdmetatarsals 14, 16 as a group about the Lisfranc ligament while thesecond metatarsal remains attached to the Lisfranc ligament.Accordingly, the Lisfranc ligament may act as a hinge or pivot pointabout which the second and third metatarsal bone group can rotate in thetransverse plane.

In other examples, the clinician may substantially independently movethe second and third metatarsals 14, 16 (e.g., by applying a separatemovement force to each metatarsal). For example, the clinician may applya force to move third metatarsal 16 in one or more planes andsubsequently apply a force to move the second metatarsal 14 in one ormore planes (or, instead, move the second metatarsal 14 followed by thethird metatarsal), such as in two or more, or all three planes. Theclinician may or may not cut or otherwise release one or moreligamentous attachments interconnecting the second and third metatarsals14, 16 to help facilitate independent repositioning of the two bones.

Independent of whether the clinician moves the second and thirdmetatarsals 14, 16 together or independently, the intermetatarsal anglebetween second and third metatarsals may or may not change duringmetatarsus adductus correction. In other words, the intermetatarsalangle between second metatarsal 14 and third metatarsal 16 may or maynot compress from a pre-corrected intermetatarsal angle to theintermetatarsal angle exhibited after correction. In someimplementations, the second and third metatarsals 14, 16 are pivoted asa group within the transverse plane without substantially changing theintermetatarsal angle between the second and third metatarsals. Forexample, the intermetatarsal angle between the second and thirdmetatarsals may change (e.g., reduce) less than 5°, such as less than2°, or less than 1° from the angle exhibited before metatarsus adductuscorrection to the angle exhibited after the correction technique isperformed.

To help facilitate movement of the second and third metatarsals in thetransverse plane, the clinician may perform a soft tissue releasebetween third metatarsal 16 and fourth metatarsal 18. The soft tissuerelease may mobilize the third metatarsal relative to the adjacentfourth metatarsal, allowing the joined second-third metatarsal boneblock to be pivoted in the transverse plane.

In addition to moving the second metatarsal and the third metatarsal inthe transverse plane, the clinician can also move fourth metatarsal 18and fifth metatarsal 20 in one or more planes (e.g., one or more of thetransverse plane, the frontal plane, and the sagittal plane), e.g., toclose the metatarsus adductus angle exhibited by those lessermetatarsals. In practice, movement of second metatarsal 14 and thirdmetatarsal 16 in one or more planes (e.g., the transverse plane) maycause the fourth and fifth metatarsals to naturally correct in same oneor more planes (e.g., the transverse plane) without requiring separatesurgical intervention on the fourth and fifth metatarsals 18, 20. Forexample, as the clinician rotates the distal end of second metatarsal 14and third metatarsal 16, either alone or in combination, the distal endsof fourth metatarsal 18 and fifth metatarsal 20 may also move laterally.The proximal base of fourth metatarsal 18 and the proximal base of fifthmetatarsal 20 may reorient relative to the cuboid bone 32, closing themetatarsus adductus angle of the fourth and fifth metatarsals. Withoutwishing to be bound by any particular theory, it is believed that forceapplied to the second and/or third metatarsal during movement maytranslate through the tissue and ligament structure interconnecting suchmetatarsal(s) to the fourth and fifth metatarsals, pulling the lessermetatarsals into realignment.

The position of fourth metatarsal 18 and fifth metatarsal 20 may correctwithout surgically accessing and preparing the metatarsal (in responseto correction of second metatarsal 14 and/or third metatarsal 16). Inother applications, however, the clinician may surgically access andprepare the bones defining fourth TMT joint 40 and/or fifth TMT joint 42in addition to or in lieu of preparing one or more other TMT joints. Forexample, before or after moving the fourth metatarsal 18 and/or fifthmetatarsal 20 in one or more planes (e.g., separate from or incombination with movement of the second metatarsal 14 and/or thirdmetatarsal 16), the clinician can surgically access and prepare thebones defining fourth TMT joint 40 and/or fifth TMT joint 42. Theclinician may decide whether to access and prepare the bones definingfourth TMT joint 40 and/or fifth TMT joint 42 depending, for example, onthe nature of the deformity being corrected and the perceived needprepare the joints for bone realignment and/or fusion

The clinician may prepare the end of fourth and/or fifth metatarsal 18,20 and/or prepare the end of cuboid bone 32 opposite the end of thefourth and/or fifth metatarsal to facilitate realignment and/or fusion.The clinician can prepare the one or more bone ends using any of thebone preparation techniques discussed herein. In various examples, theclinician may independently prepare the ends of fourth and fifthmetatarsals 18, 20 or may prepare the ends of the metatarsals together(e.g., such as positioning a single, continuous cutting guide plane overboth ends for making a continuous cut, as discussed with respect topreparation of second metatarsal 14 and third metatarsal 16).Additionally or alternatively, the clinician may prepare the portions ofthe end face of cuboid bone 32 facing fourth and/or fifth metatarsal 18,20 together or through separate preparation steps.

In instances where the clinician accesses and prepares the bonesdefining fourth TMT joint 40 and/or fifth TMT joint 42, one or both ofthe fourth metatarsal 18 and fifth metatarsal 20 may be realigned in oneor more planes in response to a force applied to the second and/or thirdmetatarsal 14, 16 (e.g., by translating the force through the tissue andligament structure interconnecting the metatarsals). Additionally oralternatively, the clinician may apply a force to the fourth metatarsal18 and/or fifth metatarsal 20 to move one or both metatarsal in one ormore planes, such as two or more, or all three planes. The fourth andfifth metatarsals 18, 20 may be moved as joined bone block (e.g., eithera bone block also connected to the bone block of the second and thirdmetatarsal 14, 16 or separate therefrom) and/or may be movedsubstantially independently from each other (e.g., by applying aseparate movement force to each metatarsal). Further, the clinician mayapply a force to move only one of the fourth or fifth metatarsals.

With typical metatarsus adductus deformities, the metatarsals mayexhibit a substantially uniplanar misalignment in the transverse plane(although may be misaligned in the frontal plane and/or sagittal plane).For this reason, the example technique of FIG. 4 has generally beendescribed as correcting the second and third metatarsals 14, 16 (and,optionally, fourth and fifth metatarsals 18, 20) in the transverseplane. The clinician may move the metatarsals in only the transverseplane to correct the generally uniplanar misalignment. Alternatively,the clinician may move one or more of the metatarsals being realigned(e.g., multiple or all of the metatarsals been realigned) in more thanone plane. For example, in addition to or in lieu of realigning themetatarsal(s) in the transverse plane, the clinician may adjust therotational angle of the metatarsal(s) in the frontal plane and/or adjustthe angle of the metatarsal(s) in the sagittal plane.

Where the clinician performs a multi-planar realignment, the clinicianmay move one or more metatarsals in multiple planes simultaneouslythrough a single movement, e.g., by moving the metatarsal in an arc orother movement pathway to adjust the position of the metatarsal inmultiple planes. The clinician may optionally perform further fineadjustment of the moved position of the one or more metatarsals, e.g.,with the aid of a bone positioning device and/or by grasping themetatarsal by hand (e.g., with the aid of a pin inserted into themetatarsal) to finalize the position of the metatarsal prior tofixation.

In other examples, the clinician may perform different movement steps tomove the one or more metatarsals in different planes. For example, theclinician may initially move the one or more metatarsals in one or twoplanes (e.g., transverse plane, frontal plane, sagittal plane) then movethe one or more metatarsals in one or two other planes (e.g., the otherof the transverse plane, frontal plane, sagittal plane), optionallyfollowed by movement of the one or more metatarsals in a third plane. Inother words, the clinician may perform different actions to move the oneor more metatarsals in different planes. Each movement step may beperformed with the aid of a bone positioning device (which may be thesame or different device for different movement steps) and/or bygrasping the metatarsal by hand (e.g., with the aid of a pin insertedinto the metatarsal).

In some examples, the clinician may move one or more of the metatarsalsbeing realigned (e.g., second metatarsal 14 and/or third metatarsal 16)proximally in the transverse plane toward the opposed bone in additionto or in lieu of moving the metatarsal(s) laterally. For example, theclinician may simultaneously move the metatarsal being realigned (e.g.,second metatarsal 14 and/or third metatarsal 16) laterally andproximally in an arc (e.g., parabola) to establish a moved position ofone or both metatarsals.

The clinician can move the one or more metatarsals being realigned(e.g., second metatarsal 14 and/or third metatarsal 16) by hand and/orwith the aid of one or more instruments. For example, the clinician cangrasp the second and/or third metatarsal and advance the distal end ofthe metatarsal laterally to reduce the metatarsus adductus angle. Theclinician may insert one or more pins into the metatarsal being moved(e.g., second and/or third metatarsal) to provide a joystick orstructure that can be grasped to manipulate movement of the bones.Additionally or alternatively, the clinician may utilize a tenaculum ortong to grasp one or both of the second and third metatarsals tofacilitate realignment.

In some examples, the clinician may use a bone positioning guide (alsoreferred to as a bone positioning device) to help apply a force to ametatarsal (e.g., second metatarsal 14 and/or third metatarsal 16) tofacilitate realignment. The bone positioning guide may include one endthat engages with (e.g., contacts, with or without being provisionallyfixated to) the metatarsal to which the force is being applied andanother end that engages with (e.g., contacts, with or without beingprovisionally fixated to) a different bone. For example, the bonepositioning guide may have one end that engages with second metatarsal14 and/or third metatarsal 16 and another end that engages with a boneother than the second and/or third metatarsals (e.g., a lessermetatarsal, a cuneiform, the cuboid bone). The bone positioning guidemay have a mechanism that urges the two ends towards each other toreduce the metatarsus adductus angle. Example bone positioning guideengagement mechanisms that can function to move the two ends of theguide toward each other include a screw or threaded rod, a ratchet, arack and pinion, and/or yet other features that translates a forceapplied by the clinician move the two ends of the bone positioning guidetoward each other. Details on an example bone positioning guide that maybe used are described in U.S. Pat. No. 9,936,994, issued Apr. 10, 2018,and titled “BONE POSITIONING GUIDE,” the entire contents of which areincorporated herein by reference.

FIG. 7A is a side perspective view of an example bone positioner 60(also referred to as a bone positioning device) that can be used to movea metatarsal relative to an adjacent bone. In some implementations, thebone positioning device includes a metatarsal engagement member, a tip,and a mechanism to move the metatarsal engagement member and the tiprelative to each other in one or more planes. For example, the mechanismmay move the metatarsal engagement member and the tip towards each other(e.g. moving the metatarsal engagement member towards the tip, movingthe tip towards the metatarsal engagement member, or moving bothsimultaneously). The bone positioning device may also include anactuator to actuate the mechanism. When the mechanism engaged, it cancause a metatarsal engaged with the metatarsal engagement member to moveto correct an alignment in at least one plane with respect to a secondbone in contact with the tip.

In the embodiment of FIG. 7A, bone positioning device 60 includes a mainbody member 62, a shaft 64, a metatarsal engagement member 66 connectedto the shaft, and a tip 68 is connected to the main body member. Ingeneral, main body member 62 can be sized and shaped to clear anatomy orother instrumentation (e.g., pins and guides) while positioned on apatient. In the embodiment of FIG. 7A, the main body member 62 isgenerally C-shaped. Although bone positioning device 60 is illustratedas being formed of two components, main body member 62 and shaft 64, theguide can be fabricated from more components (e.g., three, four, ormore) that are joined together to form the guide.

A shaft 64 can be movably connected to the main body member 62. In someembodiments, the shaft 64 includes threads 70 that engage with the mainbody member 62 such that rotation of the shaft translates the shaft withrespect to the main body member. In other embodiments, the shaft canslide within the main body member and can be secured thereto at adesired location with a set screw. In yet other embodiments, the shaftcan be moved with respect to the main body by a ratchet mechanism or yetother mechanism that rotates and/or linearly translates metatarsalengagement member 66 relative to tip 68. In the embodiment shown, theshaft moves along an axis that intersects the tip. In other embodiments,the shaft and/or metatarsal engagement member is offset from the tip.

In general, metatarsal engagement member 66 may be configured (e.g.,sized and/or shaped) to be positioned in contact, directly orindirectly, with a metatarsal to be repositioned. For example, dependingon the size and/or shape of metatarsal engagement member 66, themetatarsal engagement member may be positioned subcutaneously in contactwith a metatarsal bone to be realigned or may be positioned in contactwith an external surface of the skin overlying the metatarsal bone to berealigned. For instance, in either configuration, metatarsal engagementmember 66 may be positioned on a medial side of a metatarsal to berealigned (e.g., medial side of second metatarsal 14, third metatarsal16, fourth metatarsal 18, fifth metatarsal 20) and tip 68 positioned incontact with another bone (e.g., with or without being provisionallyfixated thereto), such as a laterally-located bone.

Metatarsal engagement member 66 may define a concave shape to generallyconform and/or wrap partially around the underling cylindrical bone. Theconcave shape may include define a continuous radius of curvature, aV-shape, a planer region between outwardly extending sidewalls, and/orother shape having a concavity. In still other examples, metatarsalengagement member 66 may be planar.

Tip 68 can be useful for contacting a bone, such as a bone differentthan the bone being moved by bone positioning device 60. For example, ifmetatarsal engagement member 66 is positioned over a medial side of onemetatarsal, the tip can be positioned over with a lateral side of adifferent metatarsal (e.g., the third, fourth, or fifth metatarsal),either directly in contact with the bone or over a lateral side of skincovering such metatarsal. In different configurations, tip 68 may bestraight or may be tapered to facilitate percutaneous insertion andcontact with bone. The tip can also include a textured surface, such asserrated, roughened, cross-hatched, knurled, etc., to reduce slippagebetween the tip and bone. In the embodiment shown, tip 68 furtherincludes a depth stop 74. Depth stop 74 can limit a depth of insertioninto an intermetatarsal space (e.g., by contacting a dorsal surface ofthe metatarsal against which tip 68 is intended to be positioned).

As shown in FIG. 7A, bone positioning device 60 can also include anactuator (e.g., a knob or a handle) 76 to actuate the mechanism, in thisembodiment associated with the shaft. In the embodiment shown, theactuator can be useful for allowing a user to rotate the shaft withrespect to the main body member 62. Actuator 76, shaft 64, and/ormetatarsal engagement member 66 may include a cannulation 78 extendingtherethrough to allow the placement of a fixation wire (e.g., K-wire)through these components and into or through a bone engaged with themetatarsal engagement member. For example, a fixation wire can be placedinto the bone engaged with metatarsal engagement member 66 to fix theposition of the metatarsal engagement member with respect to the bone.In another example, the fixation wire can be placed through the bone incontact with the metatarsal engagement member and into an adjacent boneto maintain a bone position of the bone in contact with the metatarsalengagement member and the adjacent bone. Although shaft 64 and actuator76 are illustrated as projecting away from a side of main body member62, one or both features may be positioned at a different location(e.g., extending dorsally above main body member 62 through a mechanicallinkage) to facilitate positioning of bone positioning guide 60 (e.g.,particularly metatarsal engagement member 66) in an intermetatarsalspace.

Embodiments of any instrument described herein (e.g., cutting guide,bone preparation template, bone positioning device) may include or befabricated from any suitable materials (e.g., metal, plastic). Incertain embodiments, an instrument such as a bone positioning device isfabricated at least partially from a radiolucent material such that itis relatively penetrable by X-rays and other forms of radiation, such asthermoplastics and carbon-fiber materials. Such materials are useful fornot obstructing visualization of bones using an imaging device when theinstrument is positioned on bones.

Another type of bone positioning guide that may be used to move ametatarsal in one or more planes, such as used to move second metatarsal14 and third metatarsal 16 in at least the transverse plane, is acompressor instrument. For example, when an opening (e.g., wedge-shapedopening) is created at the second and third TMT joints duringpreparation of the bone ends, a compressor may be attached to the secondand/or third metatarsal and another bone, such as the intermediatecuneiform and/or lateral cuneiform, respectively. The compressor mayapply a distal-to-proximal force across the second and/or third TMTjoints, causing the wedge-shaped opening created across the joint toclose. As the wedge-shaped opening closes, the distal end of secondmetatarsal 14 and/or third metatarsal 16 can pivot in the transverseplane. When used, the compressor may also compress the ends of the bonefaces together, e.g., by compressing intermediate cuneiform 28 andsecond metatarsal 14 together and/or compressing lateral cuneiform 30and third metatarsal 16 together, to facilitate subsequent fusion.

FIG. 7B is an illustration of an example compressor instrument 160engaged with foot 10 to facilitate movement of the second and thirdmetatarsals. In this example, compressor instrument 160 has a first end162 engaged with the second metatarsal and a second end 164 engaged withthe intermediate cuneiform. In particular, in the illustratedarrangement, first and second ends 162, 164 of compressor instrument 160are illustrated as being pinned to the bones. Compressor instrument 160can be actuated by the clinician to move the first and second ends 162,164 of the compressor towards each other. This can cause the ends of thesecond metatarsal and intermediate cuneiform to which the compressor isattached to draw towards each other, closing a wedge-shaped opening inthe TMT joint space and causing a distal end of the second metatarsal totranslate laterally. The force applied across the second TMT joint asillustrated in FIG. 7 can also close a wedge-shaped opening in the thirdTMT joint, and may move the second and third metatarsals as a bonegroup. In turn, this can cause the fourth and fifth metatarsals to alsomove in at least the transverse plane, reducing their metatarsusadductus angle.

Additional details on example compressor structures that may be used inaccordance with the disclosure are described in US Patent PublicationNo. 2020/0015856, filed Jul. 11, 2019, and titled “COMPRESSOR-DISTRACTORFOR ANGULARLY REALIGNING BONE PORTIONS,” the entire contents of whichare incorporated herein by reference. Further, while the examplecompressor instrument 160 in FIG. 7B is illustrated as being attachedacross the second TMT joint, the compressor may additionally oralternatively be attached across the third TMT joint (e.g., with firstend 162 attached to third metatarsal 16 and second end 164 attached tolateral cuneiform 30) or yet other set of bones (e.g., across the fourthTMT joint 40, across the fifth TMT joint 42).

With additional reference to FIG. 4, the example technique isillustrated as including a step of provisionally fixating the movedposition of the second metatarsal and the third metatarsal (112). Forexample, after moving the second metatarsal and third metatarsal into adesired realigned position in one or more planes, such as the transverseplane (which may also involve moving the fourth metatarsal and fifthmetatarsal), the clinician may optionally provisionally fixate the movedposition. Provisional fixation can hold the moved position of one ormore bones to facilitate subsequent surgical steps, such as applicationof one or more permanent fixation devices and/or the performance ofadditional surgical steps (e.g., first metatarsal realignment).

To provisionally fixate the moved position of the one or more bones, theclinician may insert one or more pins into and/or through a moved boneand into an adjacent bone. For example, the clinician may insert a pinthrough the second metatarsal and into an adjacent bone (e.g., acuneiform) and/or insert a pin through the third metatarsal and into anadjacent bone. The pin may be in the form of a rod and/or a wire(K-wire), and may or may not be configured to apply compression across ajoint between the bones in which the pin is inserted, e.g., by having anenlarged region of the pin that presses against the outer surface of thebone through which the tip of the pin is inserted, thereby applyingcompression.

FIG. 8A is a dorsal view of an example radiographic image illustratingan example provisional fixation pin arrangement. In this example, afirst fixation pin 170 is inserted into and through the distal base ofsecond metatarsal 14 and into the lateral cuneiform. A second fixationpin 172 is inserted into and through the distal base of third metatarsal16 and into the intermediate cuneiform.

In the illustrated configuration, the first and second pins 170, 172 areshown as crossing, with the shaft of first fixation pin 170 extending ina proximal medial to distal lateral orientation and the shaft of secondfixation pin 172 extending in a proximal lateral to distal medialorientation. In other cases, first and second pins 170, 172 may notcross but may instead be orientated in parallel, such as with the shaftsof both pins extending in a distal medial to proximal lateralorientation. FIG. 8B is a dorsal view of another example radiographicimage illustrating a provisional fixation pin arrangement in which firstand second pins 170, 172 are both positioned extending in a proximalmedial to distal lateral orientation.

The clinician may use a different number, configuration, and/orpositioning of fixation pins. For example, depending on the number ofTMT joints being prepared, the clinician may insert a provisionalfixation pin through the end of one or more of second metatarsal 14,third metatarsal 16, fourth metatarsal 18, and/or fifth metatarsal 20,with the pin extending into and/or through the end of the metatarsal andalso into another bone, such as an opposed cuneiform and/or cuboid bone.Additionally or alternatively, the clinician may insert a provisionalfixation pin through a side of one metatarsal being fixated (e.g., amedial side, lateral side) into an adjacent metatarsal).

Independent of whether the clinician deploys a provisional fixationdevice, the clinician may apply one or more permanent fixation devicesto facilitate fusion of the second and third TMT joints followingreduction of the metatarsus adduction angle (step 114 in FIG. 4). Theone or more fixation devices can extend across the second and/or thirdTMT joints to secure and hold opposed bone ends together for fusion(and/or other TMT joint in instances in which a different TMT joint isprepared for fusion). For example, the clinician may apply a firstfixation device across the second TMT joint and apply a second fixationdevice across the third TMT joint.

A bone fixation device may be any feature or combination of featuresthat holds two bone portions in fixed relationship to each other tofacilitate fusion of the bone portions during subsequent healing. Anyone or more bone fixation devices that can be used include, but are notlimited to, a bone screw (e.g., a compressing bone screw), a bone plate,a bone staple, an external fixator, an intramedullary implant, and/orcombinations thereof. Depending on the type of bone fixation deviceselected, the bone fixation device may be attached to external surfacesof the bone portions being fixated or may be installed as anintramedullary device internal to the bone portions.

In one example, the clinician may install a first bone plate across thesecond TMT joint. The first bone plate can be secured on one side tosecond metatarsal 14, bridge the second TMT joint, and be secured on anopposite side to intermediate cuneiform 28. The clinician may install asecond bone plate across the third TMT joint. The second bone plate canbe secured on one side to third metatarsal 16, bridge the third TMTjoint, and be secured on an opposite side to lateral cuneiform 30.Additionally or alternatively, the clinician may apply a U-shaped plateor other shaped plate bridging both the second and third TMT joint(e.g., with the U-shaped plate attached to the intermediate and lateralcuneiforms on the base of the U-shape and the legs of the U-shape beingattached to the metatarsals). Independent of the number of plates used,each bone plate may be secured to an underlying bone using one or morescrews, staples, and/or other securing mechanisms. When using a boneplate, each bone plate may be linear or may have a non-linear shape,such as a Y-shape, an L-shape, a T-shape, a U-shape, and/or other shapeprofile. It should be appreciated that, in this document, when terms“first” and “second” are used to modify a noun, such use is simplyintended distinguish one item from another and is not intended torequire a sequential order of preforming a procedure step unlessspecifically stated.

As briefly discussed above, a metatarsus adduction deformity may presentwith a hallux valgus misalignment in some patients. Accordingly, aclinician performing a metatarsus adduction correction procedure mayalso perform a hallux valgus correction on the patient undergoingtreatment. In the example FIG. 4, the example technique is illustratedas including a first metatarsal realignment step (116). Although thetechnique of FIG. 4 illustrates the first metatarsal realignment beingperformed after reduction and permanent fixation of the second and thirdTMT joints, a different surgical order may be performed. For example,the first metatarsal may be realigned prior to moving a lessermetatarsal (e.g., the second and third metatarsals), or may be realignedafter moving the lesser metatarsal (e.g., the second and thirdmetatarsals) but prior to permanently fixating the lesser TMT joint(s).

While the order of the surgical procedure may vary, in someapplications, it is useful to correct the alignment of one or morelesser metatarsals (e.g., second and/or third metatarsals) prior tocorrecting the alignment of the first metatarsal. By initiallycorrecting the position of the lesser metatarsal, such as the second andthird metatarsals (and, in some examples, also correcting the positionof the fourth and fifth metatarsals), the clinician may be able tobetter anatomically realign the first metatarsal relative to the alignedlesser metatarsals. Correction of the alignment of one or more of thelesser metatarsals may change the extent of misalignment of the firstmetatarsal, which can then be further corrected during a subsequentfirst metatarsal realignment step.

To correct the alignment of first metatarsal 12, the clinician maysurgically access the first TMT joint as discussed above. Once accessedthe clinician may prepare an end of first metatarsal 12 and an opposedend of medial cuneiform 26. The clinician may prepare the ends of thebones with or without cutting, as discussed above with respect topreparation of the ends of second metatarsal 14 and third metatarsal 16(e.g., using any preparation technique discussed herein). In instancesin which the clinician prepares one or more bone ends using a cuttinginstrument, the clinician may or may not utilize a cut guide to guidecontrolled cutting of the bone ends and/or a bone preparation templateto indicate where bone preparation should be performed.

Either before or after preparing one or both ends of first metatarsal 12and medial cuneiform 26, the clinician may move first metatarsal 12 inat least one plane (e.g., the transverse plane, the frontal plane) toclose an intermetatarsal angle between the first metatarsal and secondmetatarsal 14. In some examples, the clinician moves the firstmetatarsal in multiple planes, such as the transverse plane and/orfrontal plane and/or sagittal plane. The clinician may or may notutilize a bone positioning guide to facilitate movement of the firstmetatarsal relative to the second metatarsal and/or medial cuneiform.With the first metatarsal moved to a desired position, the clinician canoptionally provisionally fixate the moved position of the firstmetatarsal and then permanently fixate the moved position using one ormore bone fixation devices, such as those described above. Additionaldetails on example first metatarsal realignment instruments andtechniques that can be used are described in U.S. Pat. No. 9,622,805,issued Apr. 18, 2017 and entitled “BONE POSITIONING AND PREPARING GUIDESYSTEMS AND METHODS.”

FIGS. 9A and 9B are dorsal radiographic images of an example foot 10before and after a treatment procedure, respectively, performedfollowing an example surgical technique discussed above with respect toFIG. 4. FIG. 9A illustrates foot 10 with metatarsus adductus and halluxvalgus deformities. FIG. 9B illustrates foot 10 after realignment of thesecond and third metatarsals in at least the transverse plane andmultiplanar correction of the first metatarsal in all three planes. FIG.9B illustrates three bone plates applied across the first, second, andthird TMT joints to facilitate fusion across the three joints.

While the technique of FIG. 4 has generally been described withreference to preparation of second TMT joint 36 and third TMT joint 38and movement of both second metatarsal 14 and third metatarsal 16(optionally in combination with movement of fourth metatarsal 18 andfifth metatarsal 20), the techniques and/or devices may be performed onsingle TMT joints and/or different TMT joints without departing from thescope of the disclosure. For example, the technique of FIG. 4 may beperformed on a single lesser TMT joint, such as only the second TMTjoint 36, only the third TMT joint 38, only the fourth TMT joint 40, oronly the fifth TMT joint 42, in each case optionally in combination withpreparation of the first TMT joint 34 and realignment of the firstmetatarsal. Other combinations of joint preparation are also possible.

In applications where the clinician prepares only a single lesser TMTjoint for fusion (again, optionally as part of a procedure that alsoprepares the first TMT joint), the clinician may move the lessermetatarsal associated with that TMT joint in one or more planes, e.g.,using devices and/or techniques discussed herein. Repositioning of themetatarsal associated with the lesser TMT joint being prepared may ormay not also move one or more adjacent metatarsals to the lessermetatarsal being moved through ligamentous tissue. For example, if theclinician prepares second TMT joint 36 and moves second metatarsal 14,the repositioning of the second metatarsal may cause realignment ofthird metatarsal 16, fourth metatarsal 18, and/or fifth metatarsal 20.

As discussed above, a bone realignment technique according to thedisclosure may involve cutting an end of a cuneiform and/or an end of anopposed metatarsal. In such applications, the clinician may perform thecuts freehand or with the aid of one or more cut guides (also referredto herein interchangeably as a cutting guide). The use of a cut guidemay facilitate more accurate and repeatable cuts patient-to-patient,promoting more consistent clinical outcomes across a range of patientsan anatomical deformities. When a cut guide is used, the cut guide maygenerally define at least one guide surface positionable over a side ofthe bone to be cut, such as a dorsal side. The clinician can place acutting instrument adjacent to, and optionally in contact with, theguide surface and translate the cutting instrument relative to the guidesurface to perform a cut in a plane parallel to the guide surface. Forexample, the clinician may place the cutting instrument in contact withthe guide surface and then translate the cutting instrument relative tothe guide surface, e.g., plantarly into a bone and/or in a medial orlateral direction. The guide surface may bound movement of the cuttinginstrument to a desired direction of cutting.

FIG. 10 is a top view of foot 10 showing the example cut guide 150introduced with respect to FIG. 5A above. Cut guide 150 includes atleast one guide surface positionable over a dorsal side of a bone to becut. For example, cut guide 150 includes a guide surface 152Apositionable over a dorsal side of second metatarsal 14 and thirdmetatarsal 16. Guide surface 152A can extend straight (e.g., parallel)or an angle in a dorsal to plantar direction (in other words, in thesagittal plane) and can guide the cutting tool in a direction defined bythe guide surface. In use, the clinician can place a cutting tool inabutting relationship with guide surface 152A and advance the cuttingtool relative to the guide surface to remove an end of the metatarsalbeing cut (e.g., second metatarsal 14 and/or third metatarsal 16).

In some examples, cut guide 150 defines a single guide surface. In otherexamples, cut guide 150 may include multiple guide surfaces, for examplespaced apart from each other to define a cutting slot between the guidesurfaces. In the illustrated example, cut guide 150 is shown havingfirst metatarsal-side guide surface 152A and a second metatarsal-sideguide surface 152B parallel to the first guide surface to define acutting slot between the two guide surfaces. A clinician can insert acutting tool, such as a saw blade, in the cutting slot to guide removalof a portion of the end of second metatarsal 14 and a portion of the endof third metatarsal 16.

As discussed above with respect to FIG. 4, a clinician may independentlyprepare one or more lesser metatarsals (e.g., second metatarsal 14 andthird metatarsal 16) and/or may prepare the ends of one or more lessermetatarsals together, e.g., by making a continuous cut transecting twometatarsals. In applications where the clinician desires to make acontinuous cut transecting the two metatarsals, cut guide 150 may beconfigured with a guide surface 152A (or pair of guide surfaces 152A,152B as illustrated) extending across multiple metatarsals, such as bothsecond metatarsal 14 and third metatarsal 16. For example, the guidesurface may define a continuous guide surface extending from amedial-most side of the second metatarsal 14 to a lateral-most side ofthird metatarsal 16. This can allow the clinician to utilize the guidesurface to cut through an entirety of the second and third metatarsalsin the medial to lateral direction. When so configured, the guidesurface (e.g., cutting slot) may be sized to terminate at themedial-most side of the second metatarsal 14 and/or the lateral-mostside of third metatarsal 16 or may extend past such boundary locations.Oversizing the guide surface may allow cut guide 150 to be used onbroader patient population set. However, oversizing the guide surfacemay require closer clinician attention when making one or more cutsutilizing the guide surface.

FIG. 11 is a top view of foot 10 showing another example configurationof cut guide 150 in which the cut guide is not configured with acontinuous guide surface extending across multiple metatarsals (e.g.,second metatarsal 14 and third metatarsal 16) but instead has adiscontinuous guide surface, or two guide surfaces, separatelypositionable over each of the metatarsals. When so configured, cut guide150 may have a guide surface region positionable over each of two lessermetatarsals (e.g. second metatarsal 14 and third metatarsal 16) but adiscontinuity or break between the guide surface regions that prevents acontinuous cut from being made that transects both metatarsals. Oneguide surface may extend from a medial to a lateral side of one lessermetatarsal (e.g., second metatarsal 14), while another guide surface mayextend from a medial to a lateral side of another lesser metatarsal(e.g., third metatarsal 16). A parallel and offset guide surface 152Bmay be provided to define a cutting slot, e.g., a cut slot over thesecond metatarsal and/or third metatarsal.

With further reference to FIGS. 10 and 11, cut guide 150 is illustratedas also having a guide surface 154A positionable over a dorsal side ofintermediate cuneiform 28 and lateral cuneiform 30. Guide surface 154Acan extend straight (e.g., parallel) or an angle in a dorsal to plantardirection (in the sagittal plane) and can guide the cutting tool in aplane parallel to the guide surface. In use, the clinician can place acutting tool in abutting relationship with guide surface 154A andadvance the cutting tool relative to the guide surface to remove an endof an opposed cuneiform/cuboid bone, such as intermediate cuneiform 28and lateral cuneiform 30.

As with the metatarsal-side guide surface 152A, the cuneiform-side guidesurface 154A may define a single guide surface or may include multipleguide surfaces, for example spaced apart from each other to define acutting slot between the guide surfaces. In the illustrated example, cutguide 150 is shown having first cuneiform-side guide surface 154A and asecond cuneiform-side guide surface 154B parallel to the first guidesurface to define a cutting slot between the two guide surfaces. Aclinician can insert a cutting tool, such as a saw blade, in the cuttingslot to guide removal of a portion of the end of intermediate cuneiform28 and lateral cuneiform 30.

In some examples, the cuneiform-side guide surface 154A (or pair ofguide surfaces 154A, 154B as illustrated) extends across bothintermediate cuneiform 28 and lateral cuneiform 30. For example, theguide surface may define a continuous guide surface extending from amedial-most side of intermediate cuneiform 28 to a lateral-most side oflateral cuneiform 30. This can allow the clinician to utilize the guidesurface to perform a continuous cut to cut an end portion of both theintermediate cuneiform and the lateral cuneiform. When so configured,the guide surface (e.g., cutting slot) may be sized to terminate at themedial-most side of intermediate cuneiform 28 and the lateral-most sideof lateral cuneiform 30 or may extend past such boundary locations to beoversized.

In other examples, the cut guide is not configured with a continuousguide surface extending across intermediate cuneiform 28 and lateralcuneiform 30 but instead has a discontinuous guide surface, or two guidesurfaces, separately positionable over each of the cuneiform and/orcuboid bones. When so configured, cut guide 150 may have a guide surfaceregion positionable over each of multiple bones, such as intermediatecuneiforms 28 and lateral cuneiform 30, but a discontinuity or breakbetween the guide surface regions that prevents a continuous cut frombeing made that transects both cuneiforms. One guide surface may extendfrom a medial to a lateral side of intermediate cuneiform 28, whileanother guide surface may extend from a medial to a lateral side oflateral cuneiform 30. A parallel and offset guide surface 154B may beprovided to define a cutting slot, e.g., a cut slot over theintermediate cuneiform and/or lateral cuneiform.

While cut guide 150 is illustrated as having both a metatarsal-sideguide surface 152A and a cuneiform-side guide surface 154A, inalternative implementations, the cut guide may be configured with aguide surface for only cutting one or more metatarsals and/or one ormore cuneiform/cuboid bones. One or more separate cut guides may beutilized to cut the other of the metatarsal(s) or cuneiform(s).Alternatively, the clinician may perform cutting freehand or may performa bone preparation step that does not involve cutting the bone(s).

As still another example, cut guide may be configured to be positionedacross a single TMT joint to cut a single metatarsal and/or cuneiforminstead of being configured to be positioned across multiple metatarsalsand/or cuneiforms. FIGS. 12A and 12B are top views of foot 10 showing analternative configuration of cut guide 150 where the cut guide isconfigured (e.g., sized and/or shaped) to be positioned across thesecond TMT joint and the third TMT joint, respectively. A cut guideconfigured to be positioned across another lesser TMT joint (the fourthTMT joint, fifth TMT joint) can also be provided.

As shown in FIG. 12A, cut guide 150 has a metatarsal-side guide surface152A (which is illustrated as a cutting slot) extending from amedial-most side of second metatarsal 14 to a lateral-most side of themetatarsal. The cut guide also has a cuneiform-side guide surface 154A(which is also illustrated as a cutting slot) extending from amedial-most side of intermediate cuneiform 28 to a lateral-most side ofthe cuneiform.

With reference to FIG. 12B, cut guide 150 is illustrated with ametatarsal-side guide surface 152A (which is illustrated as a cuttingslot) extending from a medial-most side of third metatarsal 16 to alateral-most side of the metatarsal. The cut guide also has acuneiform-side guide surface 154A (which is also illustrated as acutting slot) extending from a medial-most side of lateral cuneiform 30to a lateral-most side of the cuneiform.

Cut guide 150 in FIGS. 12A and 12B may be the same cut guide that ismoved between the second TMT joint to the third TMT joint.Alternatively, the clinician may have two identical cut guides 150 thatare utilized on the different TMT joints. In still further applications,two different cut guides 150 may be provided that are configureddifferently for the second TMT joint in the third TMT joint,respectively. The cut guides may be configured differently by havingdifferent sizes and/or shapes, such as different angular orientations ofguide surfaces.

In configurations where cut guide 150 has both a metatarsal-side guidesurface and an opposed bone-side guide surface (e.g., cuneiform-sideguide surface), the guide surfaces may be parallel to each other, angledrelative to each other (e.g., to define a wedge-shaped region), orotherwise oriented relative to each other to achieve desired cutpatterns. When using an angled guide surface arrangement, the relativeangle between the two guide surfaces can define the size and shape ofbone wedge removed utilizing cut guide 150. In some examples, the anglebetween the metatarsal-side guide surface and the cuneiform-side guidesurface is fixed. In other words, the angle between the metatarsal-sideguide surface and the cuneiform-side guide surface is set during thedesign and manufacturing of the cut guide and cannot be varied by theclinician. In these examples, the clinician may be provided with asystem having a plurality of cut guides 150 (e.g., two, three, four,five, or more), where each cut guide defines different angles betweenguide surfaces. The clinician can select a cut guide with desired anglefrom the system of different guides based on the needs of the particularpatient undergoing a procedure. In other examples, however, the anglebetween the metatarsal-side guide surface and the cuneiform-side guidesurface may be adjustable. This can provide the clinician withflexibility to adjust the angular orientation between themetatarsal-side guide surface and the cuneiform-side guide surface forpatient-specific anatomical considerations.

FIG. 13 is a top view of an example configuration of cut guide 150 inwhich an angle 250 between a distal-most guide surface 152A of the cutguide (when positioned over a metatarsal) and a proximal-most guidesurface 154A of the guide (when positioned over a cuneiform or cuboid)is fixed. For many clinical applications, angle 250 may be less than 75degrees, such as less than 60 degrees, less than 45 degrees, less than35 degrees, less than 20 degrees, less than 15 degrees, less than 10degrees, or less than 5 degrees. For example, angle 250 may range from 1degree to 20 degrees, such as from approximately 5 degrees toapproximately 20 degrees, from approximately 5 degrees to approximately10 degrees, or from approximately 6 to approximately 9 degrees. In otherexamples, angle 250 may be 0 degrees (providing parallel guide surfaces)to allow for reciprocal planing, e.g., on mild cases. Bone wedges cutand/or removed according to a surgical technique according to thedisclosure may define angles within any of the forgoing angular limits(or yet different limits), whether or not cut using a cut guideaccording to the disclosure (e.g., including when cut freehand and/orwith the aid of a bone preparation template). Further, any cut guidedescribed herein having two guide surfaces angled relative to each othercan implement any of the foregoing angles or angle ranges (or yetdifferent limits).

FIG. 14A is a top view of another example configuration of cut guide 150in which the angle 250 between a distal-most guide surface 152A of thecut guide (when positioned over a metatarsal) and a proximal-most guidesurface 154A of the guide (when positioned over a cuneiform or cuboid)is variable. The two guide surfaces (which, in the illustrated example,are shown as guide slots) can be hingedly or otherwise movably connectedtogether and allowed to rotate relative to each other about a pivot axis252. The opposite end of the two guide surfaces from pivot axis 252 mayor may not be connected together. In the illustrated example, theopposite end of the two guide surfaces are movably connected togethervia a sliding connection 254. An adjustable cut guide configuration canbe adjustable within any of the example ranges of angles discussedabove.

A lock 256 may be provided to lock a desired angular orientation of thetwo guide surfaces relative to each other. Lock 256 may be implementedas a screw or other moving feature that bears against a surface toprovide frictional engagement for locking an angular orientation of theguide surfaces. As another example, lock 256 may be a projection orrecess that engages one of a series of detents to lock the angularorientation of the guide surfaces. Other features that provide a lockingfunction can be used without departing from the scope of the disclosure.When cut guide 150 is configured without a sliding connection 254 and/orlock 256, one or both of the guide surfaces may have an associatedpinhole that allows each guide surface to be pin to an underlying bonefor temporarily fixing the position of the guide surface during asurgical procedure. While cut guide 150 in FIG. 14A illustrates oneexample configuration of implementing an adjustable cut guide, otherimplementations are possible.

For example, FIG. 14B illustrates an example of cut guide 150 haveseparate guide surfaces for cutting the second and third metatarsalswhere the angular position of the guide surfaces are both adjustable. Asillustrated, the two guide surfaces are connected by a joining bar,allowing the angle of the two guide surfaces to be adjusted together(e.g., so that each guide surface defines the same angle). In otherexamples, the guide surfaces may be independently adjustable (e.g., byomitting the joining bar).

To help facilitate positioning of cut guide 150 over one or more bonesto be cut, the cut guide may include one or more locating features. Thelocating features may be insertable into a bone and/or a joint spacebetween adjacent bones to provide anatomical reference locations fororienting cut guide 150 relative to the anatomy of the foot of thepatient undergoing the clinical procedure. For example, cut guide 150may include one or more pins and/or spacers that are associated with thecut guide and used to help orient the cut guide relative to the anatomyof the patient.

As used in the present disclosure, a locating pin associated with acutting guide generally refers to a feature that is inserted into a boneand can be used to help position the cutting guide relative to a bone tobe cut. By contrast, a spacer associated with the cutting guidegenerally refers to a feature that is inserted into a joint spacebetween adjacent bones and can be used to help position the cuttingguide relative to a bone to be cut. Each feature described as a locatingpin or spacer may have any appropriate size and cross-sectional shape,including arcuate shapes (e.g., circular, oval), polygonal shapes (e.g.,square, rectangular, T-shaped), and/or combinations of arcuate andpolygonal shapes. The term locating feature encompasses both a locatingpin and/or spacer. Each locating feature may have a shaft insertableinto a bone and/or joint space.

When cut guide 150 includes one or more associated pins and/or spacers,such features can be integral with (e.g., permanently connected to) thebody of the cut guide or can be detachable and separable from the cutguide. Configuring cut guide 150 to be used with at least one locatingfeature, e.g., spacer and/or pin that can be separately installed in ajoint space between bones or in a bone, respectively, can be useful.When so configured, the spacer and/or pin may be installed independentlyof the cut guide into a bone structure and the cut guide then engagedwith the inserted spacer and/or pin. For example, the cut guide may beslide down on the locating feature, attached to a side of the locatingfeature, or otherwise operatively connected to the locating feature.Once the cut guide is installed on the locating feature, the connectionbetween the cut guide and locating feature may be fixed (e.g.,preventing relative movement between the two features) or may be arelatively movable connection (e.g., allowing rotation or other relativemovement between the two features). In either case, the spacer and/orpin can be used to identify an anatomical landmark for positioning cutguide 150 and the cut guide then engaged with the spacer and/or pin.

FIG. 15 is a perspective view of foot 10 illustrating an examplelocating feature 260, illustrated in the form of a spacer, that can beused with cut guide 150. In use, the clinician can insert locatingfeature 260 in a joint space between adjacent bones and then engage bonecutting guide 150 with the locating feature, e.g., by sliding the bonecutting guide down onto the spacer. In the specific example of FIG. 15,locating feature 260 is illustrated as being inserted into the jointspace between the medial cuneiform 26 and intermediate cuneiform 28.FIG. 16 illustrates cut guide 150 being engaged with and being advancedplantarly along locating feature 260 to help orient the bone guide overone or more bones to be cut. In particular, in the example of FIG. 16,cut guide 150 is illustrated as being oriented over a dorsal surface ofboth the second and third metatarsals as well as the intermediate andlateral cuneiforms.

As noted above, cut guide 150 can have one or more associated pinsand/or spacers, each of which can be permanently affixed to and/orseparable from the body of the cut guide. In FIG. 16, cut guide 150 isillustrated as including a first locating feature 260 from which thebody of the cut guide is separable as well as a second locating feature262, also illustrated in the form of a spacer, that is permanentlyaffixed to the body of a cut guide. Second locating feature 262 ispositioned on a different portion of the cut guide, specifically thelateral half of the cut guide in the illustrated example. As cut guide150 is engaged with first locating feature 260 (e.g., by being advancedplantarly down on locating feature 260), the clinician may rotate thecut guide about locating feature 260 in the transverse plane to positionthe second locating feature 262 over a target insertion location. Thetarget insertion location may be the third TMT joint space, asillustrated, or any other joint space and/or bone insertion location.

Cut guide 150 according to the disclosure can include any suitablenumber of locating features, which can be permanently affixed to and/orseparable from the body of the cut guide. For example, cut guide 150 mayinclude a single locating feature or multiple locating features (e.g.,two, three, or more). When configured with one or multiple locatingfeatures, the one or more locating features may be arranged at differentlocations along the body of the cut guide.

For example, one locating feature may be on a medial-most half (e.g.,medial-most quarter) of the cut guide and/or one locating feature may beon a lateral-most half (e.g., lateral-most quarter) of the cut guide,when the cut guide is positioned over bones to be cut. Additionally oralternatively, one such locating feature may be on a distal side of thecut guide (e.g., distal of a TMT joint when the cut guide is positionedover the joint) and/or one locating feature may be on a proximal side ofthe cut guide (e.g., proximal of a TMT joint when the cut guide ispositioned over the joint). In use, the clinician may rotate cut guide150 with an attached locating feature and/or about a locating feature toadjust an alignment of one or more guide surfaces relative to one ormore bones to be cut. In some examples, the cut guide (e.g., guidesurface associated therewith) has a length extending from a first end toa second end, and a locating feature is positioned at or adjacent an endof the guide to allow the guide to rotate thereabout.

The one or more locating features associated with cut guide 150 can bepositioned in any desired bones and/or joint spaces suitable forpositioning the cut guide over one or more target bones to be cut.Correspondingly, cut guide 150 can be configured (e.g., sized and/orshaped) to position one or more guide surfaces of the cut guide over oneor more target bones to be cut, when the one or more locating featuresare positioned at their target location and the cut guide is engagedtherewith.

FIGS. 23A-23I illustrate example target locations on the foot forinserting one or more locating features associated with cut guide 150 toposition the cut guide over one or more bones to be cut. The cliniciancan insert the shaft of a locating feature into the indicated jointspace, e.g., with cut guide 150 attached thereto and/or with the cutguide engageable to the locating feature after being inserted into thejoint space. While each of FIGS. 23A-23I illustrate a single joint spacelocation for inserting a locating feature associated with cut guide 150,any combination of two or more of the illustrated joint space locationsmay be utilized in combination (e.g., for cut guides employing multiplelocating features). Each locating feature of cut guide 150 may beconfigured (e.g., sized and/or shaped) to be positioned in a specifictargeted bone and/or joint space.

FIG. 23A illustrates a medial corner of the second metatarsal proximalbase and intermediate cuneiform as a target location for a locatingfeature. FIG. 23B illustrates the second TMT joint as a target locationfor a locating feature. FIG. 23C illustrates the third TMT joint as atarget location for a locating feature. FIG. 23D illustrates acombination of the second and third TMT joints as a target location fora locating feature. FIG. 23E illustrates a space between the proximalbases of the second and third metatarsals as a target location for alocating feature. FIG. 23F illustrates a space between the third andfourth metatarsals as a target location for a locating feature. FIG. 23Gillustrates a space between the intermediate and lateral cuneiforms as atarget location for a locating feature. FIG. 23H illustrates a spacebetween the mediate and intermediate cuneiforms as a target location fora locating feature. FIG. 23I illustrates the fourth TMT joint as atarget location for a locating feature.

With further reference to FIGS. 15 and 16, in some configurations of cutguide 150, the cut guide may be freely rotatable about a locatingfeature (e.g., can rotate 360° about the spacer or pin). In otherconfigurations, rotation of the cut guide relative to the spacer or pinmay be restricted within a limited angular range of movement, such as arange of 90° or less, 45° or less, or 25° or less. FIGS. 17 and 18illustrate two different configurations of cut guide 150 in which thecut guide is restricted to a limited range of rotational movementrelative to a locating feature insertable into an underlying bonestructure.

In the example of FIG. 17, a locating feature 260 is shown defining aslot 270 in which a portion of the body of cut guide 150 is inserted.Cut guide 150 can rotate within a limited range of travel defined by thesize of slot 270. In the example of FIG. 18, a locating feature 260 isshown inserted into a slot 272 defined by the body of cut guide 150.Again, cut guide 150 can rotate within a limited range of travel definedby the size of slot 272. In some examples, the limited range of rotationmovement is a bounded range less than 90 degrees, such as less than 60degrees, less than 45 degrees, less than 30 degrees, or less than 15degrees.

With further reference to FIGS. 13-18, cut guide 150 may include one ormore fixation holes 264 that allow the cut guide to be provisionallyfixated to an underlying bone. The one or more fixation holes may beconfigured to receive a fixation pin. In use, the clinician can installcut guide 150 over one or more bones to be cut and/or adjust anorientation of the one or more guide surfaces of the cut guide untilsuch one or more guide surfaces are appropriately positioned relative tothe portions of bone to be cut. For example, the clinician may rotatecut guide 150 about a locating feature (e.g., a pin or spacer), such aslocating feature 260, until the rotational position of the cut guideappropriately aligns the one or more guide surfaces of the cut guiderelative to the bones to be cut. Depending on the configuration of cutguide 150, the clinician may further adjust the relative angle 250between the guide surfaces. In either case, once cut guide 150 isappropriately positioned relative to the bones to be cut, clinician mayinsert a pin through each of the one or more fixation holes 264 into anunderlying bone. The one or more fixation pins installed throughfixation holes 264 can secure and hold cut guide 150 at a desiredposition for the clinician to subsequently utilize the cut guide toguide movement of a cutting instrument.

In some examples, cut guide 150 includes at least two parallel fixationholes 264, such as two holes positioned to be placed on the dorsal sideof two different bones separated by a joint (e.g., a metatarsal andopposed cuneiform). In use, a clinician can insert fixation pins throughthe two holes to attach the cut guide to the metatarsal and cuneiform,respectively. The clinician may remove the cut guide after use whileleaving the parallel pins in position (e.g., by sliding the cut guide upoff the parallel pins). The clinician may then insert a secondinstrument having two parallel fixation holes back down over theparallel fixation pins still remaining in the bones. For example, theclinician may insert a bone positioner and/or compressor back down overthe parallel fixation pins. The clinician can then apply a force throughthe pins using the instrument to move the bones. In addition to or inlieu of providing two parallel fixation holes, cut guide 150 may defineone or more fixation holes that are angled (at a non-zero degree angle)or otherwise skewed relative to one or more (e.g., two parallel)fixation holes.

In some configurations, the position of one or more (optionally all) ofthe fixation holes 264 defined by cut guide 150 are fixedly (e.g.,non-movably) located relative to the body of the cut guide. In practice,however, the location of patient's bone surface to a fixation hole 264defined by a cut guide may vary depending on the anatomy of the patientand extent of the patient's bone deformity. For these and other reasons,cut guide 150 can be configured with one or more adjustable fixationholes 264. A fixation hole may be adjustable in that the fixation holemay be movable relative to a length and/or width of the body of cutguide 150 and/or rotatable to adjust the orientation of the fixationhole relative to the orientation of one or more guide surfaces definedby the cut guide.

FIG. 24 is a perspective view of an example configuration of cut guide150 having at least one adjustable fixation hole 264. Cut guide 150 inFIG. 24 is illustrated as having a plurality of fixation holes264A-264D, each of which can receive a fixation pin. Cut guide 150includes at least one adjustable fixation hole 264, which is illustratedas being implemented with two adjustable fixation holes 264A, 264Blocated on different sides of the cut guide. Cut guide may also includeat least one non-adjustable fixation hole, which is illustrated as beingimplemented with two non-adjustable fixation holes 264C, 264D located ondifferent sides of the cut guide.

Each adjustable fixation hole 264A, 264B on cut guide 150 of FIG. 24 maybe defined by a hole body 180 bounding and defining the fixation hole.Hole body 180 may be attached to an arm 182 to position hole body 180offset from a remainder of the body defining the cut guide (e.g., aportion of the cut guide defining a guide surface). Hole body 180 may beoperatively and movably connected to the cut guide body, such as via arail 184 along which arm 182 can translate. Accordingly, an adjustablefixation hole 264A, 264B can move relative to the length of the bodydefining the cut guide to reposition the hole at different relativelocations along the body.

FIG. 25 is a top view of the example cut guide 150 of FIG. 24 showingexample positions to which adjustable fixation holes 264A, 264B can bemoved. In particular, FIG. 25 illustrates a first adjustable fixationhole 264A positioned at a first location (e.g., medial location) along arange of travel relative to the length of the cut guide and a secondfixation hole 264B positioned at a second location (e.g., laterallocation) along a range of travel relative to the length of the cutguide. Adjustable fixation holes 264A, 264B can be moved to differentlocations and/or can have different lengths of adjustability or travelthan illustrated without departing from the scope of the disclosure.

As mentioned, configuring cut guide 150 with one or more adjustablefixation holes can be useful to allow the fixation hole to be movedrelative to an underlying bone for pinning the cut guide to the bone.When cut guide 150 is positioned over one or more target bones to beprepared, the position of the fixation holes defined by the cut guiderelative to underlying bones may vary, e.g., depending on the positionof the holes and/or the anatomy of the patient undergoing the procedure.By providing one or more adjustable fixation holes, a fixation hole maybe moved to better align with the anatomy of the patient beforeinserting a pin through the fixation hole.

For example, FIGS. 26A and 26B are top images of an example foot showingcut guide 150 of FIGS. 24 and 25 positioned on the foot. FIG. 26Aillustrates an example arrangement in which an adjustable fixation hole264A is offset relative to a midline along the length of an underlyingbone (third metatarsal 16 in the example). FIG. 26B illustratesadjustable fixation hole 264A repositioned to be substantially centeredon the midline of the underlying bone.

Cut guide 150 may be configured with one or more adjustable fixationholes 264A, 264B. When cut guide 150 include multiple adjustablefixation holes, each of the adjustable fixation holes may moveindependently of each other. Alternatively, at least two adjustablefixation holes may be operatively connected to each other and configuredto move together. For example, FIGS. 27A and 27B are top viewillustrations of an example configuration of cut guide 150 showing anexample linkage between two adjustable fixation holes 264A, 264B. In theillustrated example, a mechanical linkage in the form of a bridge 186connects the two adjustable fixation holes 264A, 264B. Bridge 186 mayextend outwardly to a side of cut guide 150 (e.g., lateral side) and/orabove the cut guide (e.g., dorsally above). In either case, the bridgemay mechanically interconnect the two adjustable fixation holes 264A,264B such that the fixation holes move as a joined pair. Other types oflinkages between fixation holes can also be used.

While an adjustable fixation hole associated with cut guide 150 hasgenerally been described and illustrated as being translatable along thelength (e.g. parallel to the length) of the cut guide, an adjustablefixation hole may be adjustable in other dimensions relative to the cutguide in addition to or in lieu of being adjustable relative to thelength. As one example, the adjustable fixation hole may be adjustablerelative to the width of the cut guide (e.g., in the proximal to distaldirection when the cut guide is positioned on a foot). For example, arm182 connecting an adjustable fixation hole to the body of the cut guidemay have an adjustable length and/or the adjustable fixation hole may bemounted on a rail or other adjustable feature relative to the width ofthe cut guide body.

As another example, in addition to or in lieu of being adjustablerelative to the length and/or width of the cut guide body, an adjustablefixation hole may be angularly adjustable relative to the cut guide body(e.g., rotatable in the frontal plane). For example, the adjustablefixation hole may be rotatable about an axis of rotation to adjust theangle at which a pin is inserted through the fixation hole into anunderlying bone, e.g., independent of the location of the fixation holerelative to the length and/or width of the cut guide body.

FIGS. 28A and 28B are top view illustrations of an example configurationof cut guide 150 showing example rotational realignment positions for anadjustable fixation hole. In particular, FIG. 28A illustrates adjustablefixation hole 264A angularly orientated to be co-planar with adjustablefixation hole 264B. FIG. 28B illustrates adjustable fixation hole 264Arotationally realigned to position the fixation hole out of plane withadjustable fixation hole 264B. When configurated to be rotationallyadjustable, the adjustable fixation hole may rotate 360 degrees or mayrotate a lesser degree of rotation in a bounded arc, such as over arange of 180 degrees or less, such as 120 degrees or less, 90 degrees orless, or 45 degrees or less.

When using one or more adjustable fixation holes, a set screw, series ofdetents to which arm 182 can be moved, and/or other engagement/lockingfeature may be used to hold a position to which an adjustable fixationhole is moved. Accordingly, in use, a clinician may position cut guide150 over one or more bone portions to be cut using one or more guidesurfaces defined by the cut guide. The clinician may then adjust aposition of one or more adjustable fixation holes of the cut guide(e.g., in one or more dimensions) relative to underlying bones. Theclinician may adjust the position of an adjustable fixation hole so apin subsequently inserted therethrough is substantially centered about amedial line of the underlying bone. Once adjusted to a desired position,the clinician may lock the adjusted position of the fixation hole andthen insert a fixation pin through the adjusted fixation hole into anunderlying bone.

Cut guide 150 can have a variety of different configurations, asdiscussed above. For example, cut guide 150 can have one or moreassociated locating features (e.g., pins and/or spacers), each of whichcan be permanently affixed to or separable from the body of the cutguide. The pin(s) and/or spacer(s) can function as a locating featureinsertable into a bone and/or a joint space between adjacent bones,respectively, to provide anatomical reference locations for orientingcut guide 150 relative to the anatomy of the foot of the patientundergoing the clinical procedure. FIG. 19 is perspective view ofanother example implementation of cut guide 150 with associated locatingfeature 280, which is illustrated as a spacer in the form of a keel.Spacer 280 can be permanently affixed to, or detachably couplable to,cut guide 150. Spacer 280 can be configured (e.g., sized and/or shaped)to be positioned in one or more joint spaces, such as bridging acrossmultiple joint spaces of one or more bones to be cut.

As discussed above, cut guide 150 can include one or more guide surfacesconfigured to extend across multiple bones to be cut, such as acrosssecond metatarsal 14 and third metatarsal 16 and/or across intermediatecuneiform 28 and lateral cuneiform 30. Accordingly, spacer 280 may beconfigured to be positionable at least partially within multiple jointspaces, such as at least partially within the second tarsometatarsaljoint space (between second metatarsal 14 and intermediate cuneiform 28)and also at least partially within the third tarsometatarsal joint space(between third metatarsal 16 and lateral cuneiform 30). Spacer 280 canbridge across the intermetatarsal space between second metatarsal 14 andthird metatarsal 16. Configuring spacer 280 to be simultaneouslypositionable in two tarsometatarsal joint spaces can be useful toproperly align cut guide 150 relative to bones to be cut on either sideof both joint spaces.

FIG. 20 is a front perspective view of foot 10 showing cut guide 150positioned over a dorsal side of one or more bones to be cut with spacer280 inserted (plantarly) into two tarsometatarsal joint spaces. Inparticular, in the illustrated example, spacer 280 is positioned atleast partially within the second tarsometatarsal joint space and thethird tarsometatarsal joint space, with the spacer bridging across theintermetatarsal space between second metatarsal 14 and third metatarsal16. In some examples, spacer 280 is configured to contact at least amedial quarter of the end face of second metatarsal 14 and the opposedend face of intermediate cuneiform 28, such as at least a medial half,or the full end face of the second metatarsal and the intermediatecuneiform. Additionally or alternatively, spacer 280 can be configuredto contact at least a lateral quarter of the end face of thirdmetatarsal 16 and the opposed end face of lateral cuneiform 30, such asat least a lateral half, or the full end face of the third metatarsaland the lateral cuneiform. Spacer 280 can bridge across theintermetatarsal space between the two tarsometatarsal joint spaces.

In practice, certain patients may exhibit significant step off, ordistal offset, between adjacent joint planes (e.g., between the planedefining the second TMT joint and the plane defining the third TMTjoint). As a result, the patient may exhibit a protruding bone portionacross the combined joint space that spacer 280 is targeted to beinserted into. This can make it challenging for the clinician to insertspacer 280 across the adjacent joint spaces.

For example, FIG. 29 is an image of an example patient's foot 10 showinga distal offset between the second TMT joint 36 and third TMT joint 38.In this example, protruding bone portions 290 project at least partiallyacross the region between second TMT joint 36 and third TMT joint 38where spacer 280 is targeted for insertion. In particular, theillustrated example shows a proximal protruding bone tip 290 on alateral side of second metatarsal 14 and a distal protruding bone tip290 on a medial side of third metatarsal 16. To facilitate insertion ofspacer 280, the clinician may remove the one or more protruding boneportions 290, e.g., to create a pocket or continuous joint lineextending across the second TMT joint and the third TMT joint forreceiving spacer 280.

In some examples, the clinician removes the one or more protruding boneportions 290 freehand (e.g., without the aid of a cutting guide). Inother examples, however, the clinician may utilize a cut guide to helpremove the one or more protruding bone portions. FIG. 30 is perspectiveillustration of an example cut guide 292 that can be used as a planingguide to remove a protruding bone portion. FIG. 31 is top view of a footshowing an example positioning of the cutting guide of FIG. 30. As shownin this example, cut guide 292 may define at least one guide surface294A along which a cutting instrument can be guided. For example, thecut guide may define a pair of guide surfaces 294A, 294B defining acutting slot therebetween through which a cutting instrument can beinserted.

The at least one guide surface 294A of cut guide 292 can be configuredto extend at least partially across one or more bones and/or jointspaces for removing protruding bone. For example, the cut guide may besized to extend from a medial side of one or more bones (e.g., secondmetatarsal 14) to a lateral side of one or more bones (e.g., thirdmetatarsal 16). For example, the at least one guide surface 294A may besized relative to the size of a corresponding locating feature 280 ofcut guide 150 to be installed after opening the joint space using thepreliminary cut guide 292. The at least one guide surface 294A may havea length (in the medial to lateral direction) at least as long as awidth of spacer 280 (in the medial to lateral direction).

In use, the clinician can position cut guide 292 to span at leastpartially across a pair of adjacent joint spaces (e.g., second TMT jointspace 36 and third TMT joint space 38). For example, the clinician canposition cut guide 292 on a dorsal side of the foot substantiallycentered between the two joint spaces (e.g., substantially centered atthe intersection between the proximal bases of second metatarsal 14 andthird metatarsal 16). The clinician can then guide a cutting instrumentalong the at least one guide surface 294A to remove protruding boneportion(s). This can create an opening or pocket into which spacer 280can then be inserted.

To help position cut guide 292 spanning over one or more joint spaces,the cut guide may include one or more locating features. For example,cut guide 292 may include a first locating feature 296A on a medial sideof the cut guide and a second locating feature 296B on a lateral side ofthe cut guide. The two locating features may have a comparatively smallcross-sectional area and be separated by a gap. As a result, firstlocating feature 296A can be positioned on a medial side of second TMTjoint space 36 and second locating feature 296B can be positioned on alateral side of third TMT joint space 38, with the gap spanning anyprotruding bone portions to be excised using the cut guide.

While cut guide 292 may be useful to open a receiving cavity betweenadjacent joint spaces for subsequently inserting a locating feature, thecut guide can be used for other purposes as well. For example, cut guide292 may be used as an axillary instrument to remove a portion of a boneend, e.g., as part of a revision procedure or trimming on a bone endafter removing an initial portion of bone using cut guide 150. Asanother example, the clinician may use cut guide 292 to prepare a jointfor fusion, e.g., by making a substantially planer cut on the end facesof both bones facing the joint space to promote fusion. This can beuseful, for example, to prepare an arthritic joint for fusion, which maybe done with or without realignment of a bone defining the joint beforeor after preparing the bone end.

In addition, cut guide 292 is illustrated as having an optional handle298 extending upwardly and outwardly away from the at least one guidesurface of the cut guide. Any cut guide described herein may or may nothave a handle, such as handle 298, to aid clinician manipulation of thecut guide. When used, the handle can be permanently and integrallyconnected to the remainder of the cut guide or may be detachablyconnected to the remainder of the cut guide (e.g., to the allow thehandle to be removed after positioning the remainder of the cut guide ata desired location). If desired, the clinician may grasp the handle tohold the cut guide in position (e.g., with or without pinning the cutguide to underlying bones) while making one or more cuts.

With further reference to FIG. 19, cut guide 150 includes at least oneguide surface positionable over a dorsal side of a bone to be cut. Inthe illustrated example of FIG. 19, cut guide 150 includes a firstmetatarsal-side guide surface 152A and a second metatarsal-side guidesurface 152B parallel to the first guide surface to define a cuttingslot between the two guide surfaces. The cut guide also includes a thirdmetatarsal-side guide surface 152C and a fourth metatarsal-side guidesurface 152D parallel to the third guide surface to define a secondcutting slot between the two guide surfaces. The second cutting slot ispositioned distally of the first cutting slot.

In addition, cut guide 150 in FIG. 19 includes a first cuneiform-sideguide surface 154A and a second cuneiform-side guide surface 154Bparallel to the first guide surface to define a cutting slot between thetwo guide surfaces. The cut guide also includes a third cuneiform-sideguide surface 154C and a fourth cuneiform-side guide surface 154Dparallel to the third guide surface to define a second cutting slotbetween the two guide surfaces. The second cuneiform-side cutting slotis positioned proximally of the first cuneiform-side cutting slot. Cutguide 150 can have a different number or arrangement of guide surfaces,as discussed above.

Configuring cut guide 150 with multiple guide surfaces (e.g., cuttingslots) offset (e.g., proximally or distally) from each other can beuseful to provide the clinician with flexibility in selecting the amountof bone to remove. The clinician can select one of multiple parallelguide surfaces (e.g., two, three, four, or more guide surfaces) based onthe desired amount of bone to be removed and guide a cutting instrumentalong the selected guide surface to remove the desired amount of bone.Configuring cut guide 150 with multiple guide surface can also be usefulto allow revision cuts. For example, after the clinician removes aninitial amount of bone using one guide surface, the clinician may decidethat additional bone removal is appropriate to achieve the desiredcorrection. Accordingly, the clinician may reuse the same cut guide,selecting a different guide surface farther along the length of the boneto remove an additional portion of bone. Any configuration of cut guide150 described herein can include multiple guide surfaces (e.g., cuttingslots) spaced from each other (e.g., proximally and/or distally), whichmay or may not be parallel aligned to each other, to facilitate removingdifferent amounts of bone depending on the specific guide surfaceselected by the clinician.

With reference to FIG. 19, cut guide 150 may be configured with acontinuous guide surface configured to extend across two bones to be cut(e.g., from a medial-most side of the second metatarsal 14 to alateral-most side of third metatarsal 16) or may have a discontinuousguide surface with separate portions configured to be positioned overseparate bones to be cut. In either case, cut guide 150 may define anon-zero degree angle 282 between the portion of one or more guidesurfaces configured to be positioned over a medial bone to be cut (e.g.,second metatarsal 14, intermediate cuneiform 28) and the portion of oneor more guide surfaces configured to be positioned over a lateral boneto be cut (e.g., third metatarsal 16, lateral cuneiform 30). Angling themedial and lateral portions of cut guide 150 relative to each other maybe useful to orient the guide surface(s) defined by the guide relativeto the anatomical contour of the foot, e.g., as illustrated in FIG. 20.In some examples, cut guide 150 defines an angle 282 between a guidesurface to be positioned over a medial bone and a guide surface to bepositioned over an adjacent lateral bone ranging from 90 to 179 degrees,such as from 110 to 175 degrees, from 125 to 170 degrees, or from 135 to165 degrees.

When cut guide 150 is configured with an angled shape between medial andlateral portions of the cut guide, both the plantar side of the cutguide (e.g., bone contacting surface of the cut guide) and the dorsalside of the cut guide (e.g., outward facing side of the cut guide) maybe angled. For example, FIG. 19 illustrates both the bone contactingside 284 of cut guide 150 and the outward facing side 286 of the cutguide being angled at substantially the same angle 282. This arrangementmay be useful so the bone contacting side 284 of cut guide 150 conformsto the profile of the underlying bones and this profile is observable tothe clinician through the mirrored profile on the outward facing side286 of the cut guide. In other examples, however, one or both sides 284,286 of the cut guide may be straight (e.g., non-angled) or the bonecontacting side 284 may be angled at a different degree of angulationthan the outward facing side 286 of the cut guide.

While cut guide 150 may define a sharp transition between the differentplanes defining the bone facing surfaces and/or outward facing surfacesof the cut guide, in other examples, the cut guide may define a curvedbone facing surface and/or outward facing surface to effect thetransition between the different planes defined by the bones. Forexample, the bone facing surface 284 of cut guide 150 may define acurved profile that positions the bone facing surface in contact withthe dorsal surfaces of the underlying bones. The outward facing surface286 may or may not mirror the curved bone facing surface.

In practice, angling and/or curving the outward facing surface 286 ofcut guide 150 can be useful so the lateral portion of the cut guide isoffset plantarly relative to the medial portion of the cut guide. Thismay help the clinician visualize the sagittal plane offset between thesecond and third metatarsals. For example, the clinician may beinstructed to move the cutting instrument perpendicular to the outwardfacing surface of cutting guide 150, resulting in an angularreorientation of the cutting instrument as the instrument moves to theangled lateral portion of the cutting guide. This can help prevent theclinician from inadvertently cutting into the adjacent fourthmetatarsal.

To help guide the clinician's cutting motion and/or to help preventinadvertent cutting of an adjacent metatarsal, a blocking or fencingelement may be positioned on a side (e.g., lateral side) of the cutguide. FIG. 32 is a perspective illustration of a foot showing anexample cut guide 150 and blocking element 288, where the blockingelement is positioned to limit movement of a cutting instrument to helpprevent inadvertent cutting of an adjacent metatarsal. The blockingelement may be a pin, osteotome, or other feature. Blocking element 288can be connected to cut guide 150 or may be a separate feature from thecut guide. Blocking element 288 may define a length extending above theuppermost surface of cut guide 150. For example, blocking element 288may extend to a height above the dorsal surface of a metatarsal that isat least twice the height to which the upper surface of cut guide 150extends. In the illustrated example, blocking element is insertedbetween third metatarsal 16 and fourth metatarsal 18. In either case,blocking element 288 may function as a visual and/or tactile barrier tolimit the lateral motion of a cutting instrument by a clinician.

In use, spacer 280 can be positioned at least partially within twodifferent and adjacent joint spaces, where each joint space separatestwo opposed bone ends. This can orient the one or more guide surfaces ofcutting guide 150 over the dorsal surfaces of adjacent bone ends to becut. FIG. 21 is a top view of foot 10 illustrating an exampleconfiguration of cutting guide 150 positioned over adjacent bone ends tobe cut, with spacer 280 inserted into adjacent joint spaces defined bythe bone ends to be cut. Cutting guide 150 in FIG. 21 is illustrated ashaving a single cuneiform-side cutting slot and a single metatarsal-sidecutting slot, although can have different designs as discussed above.

In general, spacer 280 may extend from a first end attached to, orattachable to, cut guide 150 to a second end insertable plantarly intoadjacent joint spaces. In some examples, such as the example of FIG. 19,spacer 280 may taper in width (e.g., the distance the spacer spansacross the adjacent joint spaces) and/or thickness from the first end tothe second end. In other examples, spacer 280 may have a constant widthand/or thickness over the length of the spacer.

In FIG. 19, spacer 280 is illustrated as a block insertable intoadjacent tarsometatarsal joint spaces, with the spacer block spanningbetween the two tarsometatarsal joint spaces. In other examples, cutguide 150 may be attached to, or attachable to, two spacers separatelypositionable in adjacent joint spaces, with a gap or void space betweenthe two spacers. For example, FIG. 22 is a perspective view of anotherconfiguration of cut guide 150 showing the cut guide associated with twospacers 280A, 280B. Spacer 280A may be positioned in a firsttarsometatarsal joint space (e.g., between second metatarsal 14 andintermediate cuneiform 28), and spacer 280B may be positioned in asecond first tarsometatarsal joint space (e.g., between third metatarsal16 and lateral cuneiform 30).

While the foregoing description of cut guide 150 and associated locatingfeature(s) has generally focused on a configuration for positioning overthe second tarsometatarsal joint and the third tarsometatarsal joint,the cut guide can be configured to cut any tarsometatarsal joint orcombination of joints. For example, cut guide 150 and associatedlocating feature(s) (when used) can be configured for positioning one ormore guide surfaces over one or more bone ends defining the thirdtarsometatarsal joint and fourth tarsometatarsal joint, or the fourthtarsometatarsal joint and fifth tarsometatarsal joint, instead of thesecond and third tarsometatarsal joints. Accordingly, discussion ofinstruments and techniques for preparing an end of second metatarsal 14and/or and end of intermediate cuneiform 28 (and/or an end of thirdmetatarsal 16 and/or an end of lateral cuneiform 30) should beunderstood to apply equally to other lesser tarsometatarsal joint spacesand/or other bone ends.

Further, reference to a metatarsal-side and cuneiform-side for anydevice herein (e.g., bone positioner, cut guide) is intended to describerelative positions and orientations of features where the device crossesa TMT joint with a metatarsal on one side and a cuneiform on anotherside. Where the device is deployed across two different bones, such asthe fourth metatarsal and the cuboid bone or yet other two bones or boneportions (e.g., two bone portions separated by a joint), the terminologycan be changed based on that anatomy.

While the foregoing description of techniques and instruments hasincluded discussion of example cut guides, it should be appreciated thata portion or all of one or more techniques can be performed without theuse of a cut guide. For example, a technique according to disclosure maybe performed freehand (without the use of a cutting guide) or with theaid of a bone preparation template in addition to or in lieu of using acut guide. In general, a bone preparation template may be a device thatis configured (e.g., sized and/or shaped) to overlay one or more boneportions to be subsequently cut. The bone preparation template may beconfigured to indicate where on the underlying bone the bone should becut or otherwise prepared. Positioning the bone preparation template onthe underlying bone may mark or otherwise indicate on the bone where thebone should be prepared and/or the clinician may use the bonepreparation template to mark where on the bone the bone should beprepared. The clinician may subsequently remove the bone preparationtemplate and preform a bone preparation step (e.g., cutting) at thelocation marked or otherwise indicated using the template.

As one example, the bone preparation template may have a sharpenedsurface, such as a sharpened surface projecting plantarly on abone-contacting side of the bone preparation template. The sharpenedsurface can be implemented as chisel, scoring line, or other featurethat imparts an indicating mark or marks on a surface (e.g., bonesurface) that is contacted by the feature. The clinician can positionthe template relative to one or more bones to be prepared, for example,using one or more locating features and/or other orienting features, toposition the template relative to one or more target anatomicallocations of the patient. As the template contacts one or more bonesurfaces (e.g., by the clinician pressing the template downwardlyagainst the bone surface and/or sliding the template back and forthrelative to the bone), the sharpened surface may impart an indicatingmark on the bone. Additionally or alternatively, the clinician may applyenergy (e.g., radio-frequency current, laser energy) through and/oradjacent to the template to burn, score, and/or otherwise generate anindicating mark on one or more bones. The clinician can subsequentlyperform freehand bone preparation (e.g., cutting) using a tissueremoving instrument that follows or traces the indicating mark.

As another example, a bone preparation template may include a lightsource (e.g., built-in laser light or other light targeting device) thatdisplays a light template on and/or over one or more bones. The lightsource may be positioned relative to one or more bones to be prepared,for example, using one or more locating features and/or other orientingfeatures to position the light source relative to one or more targetanatomical locations of the patient. The light source can be activatedto display one or more light lines or other indicating light marks onand/or over one or more bones to be prepared. The clinician can performfreehand bone preparation (e.g., cutting) using a tissue removinginstrument that follows or traces the marks or lines broadcast by thelight source.

As another example, the bone preparation template may be a shapedstructure (e.g., fabricated of metal or plastic) that has one or moreguide surfaces (e.g., optionally without slots) that can be used toguide a marking source. The guide surface to guide a marking instrumentcan be positioned relative to one or more bones to be prepared, forexample, using one or more locating features and/or other orientingfeatures to position the surface relative to one or more targetanatomical locations of the patient. The clinician can then use thetemplate to guide a marking source (e.g., a surgical marker pen, scalpelor other sharp instrument to scribe or mark a bone surface) to impartone or more indicating marks on the bone surface to be prepared. Theclinician can subsequently perform freehand bone preparation (e.g.,cutting) using a tissue removing instrument that follows or traces theindicating mark. FIG. 33 is a perspective view of an example bonepreparation template 300 that defines one or more guiding surfaces 302that can be used to guide a marking instrument.

In any configuration of a bone preparation template, the template may beused to designation bone preparation locations (e.g., one or more cutlines) that can be used by the clinician to prepare one or more boneend. The bone preparation locations can be those discussed above withrespect to a cut guide, resulting in removed bone portions and/or jointopenings, e.g., as discussed as being generated with a cut guide. Also,the locating features used with the bone preparation template can bethose discussed above with respect to a cut guide. A bone preparationtemplate as described herein can be used to prepare any bone orcombination of bones, including a first metatarsal and/or one or morelesser metatarsals.

Various examples have been described. These and other examples arewithin the scope of the following claims.

1. A method for treating metatarsus adductus comprising: cutting an endof at least one of a second metatarsal and an intermediate cuneiform tocreate an opening between the end of the second metatarsal and theintermediate cuneiform; cutting an end of at least one of a thirdmetatarsal and a lateral cuneiform to create an opening between the endof the third metatarsal and the lateral cuneiform; moving the secondmetatarsal and the third metatarsal in at least a transverse plane toclose a metatarsus adductus angle; and fixating a moved position of thesecond metatarsal and the third metatarsal.
 2. The method of claim 1,wherein moving the second metatarsal and the third metatarsal comprisesmoving the second metatarsal and the third metatarsal together as ajoined bone group.
 3. The method of claim 2, wherein moving the secondmetatarsal and the third metatarsal together as a joined bone groupcomprises preserving ligamentous attachments between the secondmetatarsal and the third metatarsal.
 4. The method of claim 2, whereinmoving the second metatarsal and the third metatarsal together as ajoined bone group comprises moving the second metatarsal and the thirdmetatarsal without significantly changing an intermetatarsal anglebetween the second metatarsal and the third metatarsal.
 5. The method ofclaim 1, wherein moving the second metatarsal and the third metatarsalin at least the transverse plane comprises pivoting the secondmetatarsal and the third metatarsal in the transverse plane about amedial aspect of the second metatarsal.
 6. The method of claim 1,further comprising: preparing an end of the other of the secondmetatarsal and the intermediate cuneiform; and preparing an end of theother of the third metatarsal and the lateral cuneiform.
 7. The methodof claim 6, wherein cutting the end of at least one of the secondmetatarsal and the intermediate cuneiform and preparing the end of theother of the second metatarsal and intermediate cuneiform comprisescutting the end of the second metatarsal and cutting the end of theintermediate cuneiform.
 8. The method of claim 6, wherein cutting theend of at least one of the third metatarsal and the lateral cuneiformand preparing the end of the other of the third metatarsal and lateralcuneiform comprises cutting the end of the third metatarsal and cuttingthe end of the lateral cuneiform.
 9. The method of claim 1, wherein:cutting the end of at least one of the second metatarsal and theintermediate cuneiform to create the opening comprises cutting the endof at least one of the second metatarsal and the intermediate cuneiformto create a wedge-shaped opening; and cutting the end of at least one ofthe third metatarsal and the lateral cuneiform to create the openingcomprises cutting the end of at least one of the third metatarsal andthe lateral cuneiform to create a wedge-shaped opening.
 10. The methodof claim 9, wherein: cutting the end of at least one of the secondmetatarsal and the intermediate cuneiform to create the wedge-shapedopening comprises making a cut angled in the transverse plane to createa wedge-shaped section of bone, and further comprising, prior to movingthe second metatarsal, removing the wedge-shaped section of bone, andcutting the end of at least one of the third metatarsal and the lateralcuneiform to create the wedge-shaped opening comprises making a cutangled in the transverse plane to create a wedge-shaped section of bone,and further comprising, prior to moving the third metatarsal, removingthe wedge-shaped section of bone.
 11. The method of claim 9, wherein:moving the second metatarsal in the transverse plane comprises closingthe wedge-shaped opening between the end of the second metatarsal andthe intermediate cuneiform; and moving the third metatarsal in thetransverse plane comprises closing the wedge-shaped opening between theend of the third metatarsal and the lateral cuneiform.
 12. The method ofclaim 1, further comprising, prior to fixating the moved position,compressing the end of the second metatarsal against the end of theintermediate cuneiform and compressing the end of the third metatarsalagainst the end of the lateral cuneiform.
 13. The method of claim 1,further comprising engaging a bone positioning guide with at least oneof the second metatarsal and the third metatarsal and a bone other thanthe second metatarsal and the third metatarsal, wherein moving thesecond metatarsal and the third metatarsal in the transverse planecomprises engaging the bone positioning guide.
 14. The method of claim13, wherein the bone positioning guide is a compressor, and engaging thebone positioning guide with at least one of the second metatarsal andthe third metatarsal comprises attaching the compressor to at least oneof: the intermediate cuneiform and the second metatarsal, and thelateral cuneiform and the third metatarsal.
 15. The method of claim 13,wherein the bone positioning guide is engaged with (a) at least one of amedial side of the second metatarsal and a medial side of the thirdmetatarsal and (b) a bone other than the second metatarsal and the thirdmetatarsal.
 16. The method of claim 1, wherein moving the secondmetatarsal and the third metatarsal in at least the transverse plane toclose the metatarsus adductus angle further comprises moving a fourthmetatarsal and a fifth metatarsal in at least the transverse plane. 17.The method of claim 1, further comprising provisionally fixating a movedposition of the second metatarsal and the third metatarsal.
 18. Themethod of claim 17, wherein provisionally fixating the moved position ofthe second metatarsal and the third metatarsal comprises inserting a pinthrough the third metatarsal and into the intermediate cuneiform. 19.The method of claim 1, wherein fixating the moved position of the secondmetatarsal and the third metatarsal comprises: applying at least onefixation device across a second tarsal-metatarsal joint between thesecond metatarsal and the intermediate cuneiform, and applying at leastone fixation device across a third tarsal-metatarsal joint between thethird metatarsal and the lateral cuneiform.
 20. The method of claim 19,wherein: applying at least one fixation device across the secondtarsal-metatarsal joint comprises attaching a first plate to the secondmetatarsal and to the intermediate cuneiform, and applying at least onefixation device across the third tarsal-metatarsal joint comprisesattaching a second plate to the third metatarsal and to the lateralcuneiform.
 21. The method of claim 1, further comprising realigning afirst metatarsal by at least; preparing an end of the first metatarsal;preparing an end of a medial cuneiform facing the first metatarsal;moving the first metatarsal in at least the transverse plane to close anintermetatarsal angle between the first metatarsal and the secondmetatarsal; and fixating a moved position of the first metatarsal. 22.The method of claim 21, wherein moving the first metatarsal in at leastthe transverse plane further comprises rotating the first metatarsal ina frontal plane.
 23. The method of claim 22, wherein realigning thefirst metatarsal comprises realigning the first metatarsal after movingthe second metatarsal and the third metatarsal.
 24. The method of claim1, further comprising: positioning a cutting guide defining a guidesurface over a dorsal side of the second metatarsal and over a dorsalside of the third metatarsal, and using the guide surface to advance acutting tool along the guide surface to remove a portion of the end ofthe second metatarsal and to remove a portion of the end of the thirdmetatarsal.
 25. The method of claim 24, wherein the guide surfacecomprises a continuous guide surface extending from a medial-most sideof the second metatarsal to a lateral-most side of the third metatarsal.26. The method of claim 24, wherein the guide surface defines a firstguide surface, and further comprises a second guide surface parallel tothe first guide surface to define a cutting slot between the first guidesurface and the second guide surface, wherein using the guide surface toadvance the cutting tool in the plane parallel to the guide surfacecomprises advancing the cutting tool in the cutting slot.
 27. The methodof claim 24, wherein positioning the cutting guide over the dorsal sideof the second metatarsal and over the dorsal side of the thirdmetatarsal comprise at least one of: inserting a pin associated with thecutting guide into a bone; and inserting a spacer associated with thecutting guide between adjacent bones.
 28. The method of claim 27,wherein the at least one of the pin and the spacer is separable from thecutting guide, and inserting at least one of the pin and spacercomprises at least one of: inserting the pin into the bone and slidingthe bone cutting guide onto the pin; and inserting the spacer betweenadjacent bones and sliding the bone cutting guide onto the spacer. 29.The method of claim 27, wherein the bone cutting guide comprises atleast one fixation hole, and further comprising, after sliding the bonecutting guide onto the at least one of the pin and the spacer, insertinga pin through the at least one fixation hole into an underlying bone tofix a position of the bone cutting guide.
 30. The method of claim 1,wherein cutting the end of at least one of the second metatarsal and theintermediate cuneiform comprises cutting the end of the secondmetatarsal and cutting the end of the intermediate cuneiform, andcutting the end of at least one of the third metatarsal and the lateralcuneiform comprises cutting the end of the third metatarsal and cuttingthe end of the lateral cuneiform, and further comprising: positioning acuneiform-side guide surface of a cutting guide over a dorsal side ofthe intermediate cuneiform and over a dorsal side of the lateralcuneiform, positioning a metatarsal-side guide surface of the cuttingguide over a dorsal side of the second metatarsal and over a dorsal sideof the third metatarsal, using the cuneiform-side guide surface toadvance a cutting tool parallel to the cuneiform-side guide surface toremove a portion of the end of the intermediate cuneiform and to removea portion of the end of the lateral cuneiform, and using themetatarsal-side guide surface to advance the cutting tool parallel tothe metatarsal-side guide surface to remove a portion of the end of thesecond metatarsal and to remove a portion of the end of the thirdmetatarsal.
 31. The method of claim 30, wherein the cuneiform-side guidesurface comprises a continuous cuneiform-side guide surface extendingfrom a medial-most side of the intermediate cuneiform to a lateral-mostside of the lateral cuneiform.
 32. The method of claim 30, wherein themetatarsal-side guide surface comprises a continuous metatarsal-sideguide surface extending from a medial-most side of the second metatarsalto a lateral-most side of the third metatarsal.
 33. The method of claim30, wherein the metatarsal-side guide surface comprises a firstcuneiform-side guide surface extending across the second metatarsal anda second cuneiform-side guide surface extending across the thirdmetatarsal.
 34. The method of claim 30, wherein: the cuneiform-sideguide surface defines a first cuneiform-side guide surface, and furthercomprising a second cuneiform-side guide surface parallel to the firstcuneiform-side guide surface to define a cuneiform-side cutting slottherebetween, wherein using the cuneiform-side guide surface to advancethe cutting tool in the plane parallel to the cuneiform-side guidesurface comprises advancing the cutting tool in the cuneiform-side guidesurface cutting slot, and the metatarsal-side guide surface defines afirst metatarsal-side guide surface, and further comprising a secondmetatarsal-side guide surface parallel to the first metatarsal-sideguide surface to define a metatarsal-side cutting slot therebetween,wherein using the metatarsal-side guide surface to advance the cuttingtool in the plane parallel to the metatarsal-side guide surfacecomprises advancing the cutting tool in the metatarsal-side guidesurface cutting slot.
 35. The method of claim 30, wherein an anglebetween the cuneiform-side guide surface and the metatarsal-side guidesurface is fixed.
 36. The method of claim 30, wherein an angle betweenthe cuneiform-side guide surface and the metatarsal-side guide surfaceis adjustable, and further comprising, prior to using the cuneiform-sideguide surface and using the metatarsal-side guide surface to advance thecutting tool, setting the angle between the cuneiform-side guide surfaceand the metatarsal-side guide surface.
 37. A method for treatingmetatarsus adductus comprising: positioning a cuneiform-side guidesurface of a cutting guide over a dorsal side of an intermediatecuneiform and over a dorsal side of a lateral cuneiform; positioning ametatarsal-side guide surface of the cutting guide over a dorsal side ofa second metatarsal opposing the intermediate cuneiform and over adorsal side of a third metatarsal opposing the lateral cuneiform; usingthe cuneiform-side guide surface to advance a cutting tool along thecuneiform-side guide surface to remove a portion of the intermediatecuneiform and to remove a portion of the lateral cuneiform; using themetatarsal-side guide surface to advance the cutting tool along themetatarsal-side guide surface to remove a portion of the secondmetatarsal and to remove a portion of the third metatarsal; moving thesecond metatarsal and the third metatarsal in a transverse plane toclose a metatarsus adductus angle; provisionally fixating a movedposition of the second metatarsal and the third metatarsal; andpermanently fixating the moved position of the second metatarsal and thethird metatarsal.